Megan M. Hennessey, MD1, Sara R.. Zelman, MD1, Jay C. Buckey, MD1, Corey A. Siegel, MD, MS2 1Dartmouth Hitchcock Medical Center, Lebanon, NH; 2Dartmouth-Hitchcock Inflammatory Bowel Disease Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
Introduction: Ulcerative colitis (UC) is characterized in part by a dysregulated response to tissue hypoxia. While intravenous (IV) steroids are the mainstay of treatment for acute severe UC (ASUC), up to one-third of patients are refractory to steroids alone and require rescue therapy. Evidence shows hyperbaric oxygen therapy (HBO2) can be an effective short-term treatment option for patients hospitalized with UC flares.
Case Description/Methods: 71-year-old female with extensive ulcerative colitis on infliximab presented with abdominal pain and more than 10 bloody bowel movements per day. Labs were notable for WBC 12, Hgb 11, and CRP 56. Her infliximab level was undetectable with an antibody level of 86.8 U/mL (upper limit of normal < 50 U/mL). Flexible sigmoidoscopy on hospital day (HD)1 showed Mayo 3 colitis; biopsies for CMV were negative. She was started on hydrocortisone 100mg IV every eight hours and given one dose of vedolizumab with improvement in her CRP from 56 to 40. Hyperbaric oxygen (HBO2) treatments were offered but declined. By HD5, she was clinically improving with CRP down to 9 and she was transitioned from IV to oral steroids. Unfortunately, after starting PO steroids she developed a relapse of symptoms. Her CRP increased rapidly from 9 to 48, prompting re-initiation of IV steroids on HD6. Given her inability to tolerate switching from IV to oral steroids, and concern that her UC flare may be medically refractory, colorectal surgery was consulted. Hyperbaric medicine was re-engaged to prevent progression to colectomy. She completed 5 HBO2 treatments (HD 7-11) with prompt reduction in both CRP and stool frequency with resolution of bleeding (Figure 1). After 3 HBO2 treatments she transitioned successfully from IV to oral steroids on HD9. She was discharged on oral prednisone and outpatient vedolizumab infusions.
Discussion: This case demonstrates the potential of HBO2 therapy to help patients transition successfully from IV to PO steroids who were previously refractory to de-escalation. HBO2 therapy should be considered as an adjunctive treatment option for patients with severe UC flares both to help potentiate effects of standard therapies and avoid progression to colectomy. It may also help expedite time to discharge and bridge the gap between induction therapy with biologics and the onset of their effects.
Figure: Figures 1: Red lines show C-reactive protein (CRP) levels. Blue lines show stool frequency. She was discharged on HD 12 and had a follow up appointment on day 25 after admission.
Disclosures:
Megan Hennessey indicated no relevant financial relationships.
Sara Zelman indicated no relevant financial relationships.
Jay Buckey indicated no relevant financial relationships.
Megan M. Hennessey, MD1, Sara R.. Zelman, MD1, Jay C. Buckey, MD1, Corey A. Siegel, MD, MS2. P2242 - Hyperbaric Oxygen Enabled a Transition to Oral Steroids in an Acute Severe Ulcerative Colitis Flare, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
