P2230 - Kratom-Induced Flare of Acute Severe Ulcerative Colitis

Syed Adeel Hassan, MBBS, MD¹, Ivana Deyl, MD¹, Courtney L. Perry, DO, MS¹, Aaron B. Fein, DO¹, Sai Srikar Venkata, ², Terrence A.. Barrett, MD^1
1University of Kentucky, Lexington, KY; ²Stanley Medical College, Chennai, Tamil Nadu, India

Introduction: Kratom is an herbal alternative to opioids. Lack of manufacturing and dispensing regulations pose a great threat. Kratom-induced liver injury, and multiorgan dysfunction are well reported. Risk in ulcerative colitis (UC) is yet to be established. We present the first ever case of kratom induced flare of ulcerative colitis.

Case Description/Methods: A 36 y/o male with UC presents with 12 bloody bowel movements (BM) and left sided-abdominal pain. Disease was well controlled on upadacitinib (UPA) 30 mg/day (Figure 1). No history of travel or sick contact. Within 2 months of starting kratom 8.4 g/day, he developed worsening BM with fecal calprotectin (FC) >3000 ug/g, CRP 28 mg/L and culture positive salmonella. CT showed wall thickening of rectum, and transverse colon. Ciprofloxacin and UPA 45 mg q8 weeks were started. At discharge, 4 BM/day without blood, abdominal pain or elevated CRP (6.1 mg/L) were noted.

Patient was re-hospitalized 3 weeks later with CRP 59.3 mg/L and negative infectious labs. Colonoscopy revealed pan-colonic UC (Mayo 3) with features of severe UC on pathology. 10 mg/kg infliximab (IFX) plus azathioprine (AZA) 50 mg/day was started. Symptoms resolved and CRP normalized 3.8 mg/L. He discontinued kratom post discharge for 10 days. This corresponded with clinical resolution with formed non-bloody BM, no abdominal pain and CRP < 3 mg/L.

After discharge, patient re-started kratom leading to hospitalization for 15 bloody BM/day, severe abdominal pain and CRP 20.5 mg/L. Colonoscopy revealed moderate UC (cecum to sigmoid colon: Mayo 2) and mild UC (rectosigmoid to rectum: Mayo 1). Prednisone 40mg/day added to IFX/AZA therapy with resolution of clinical symptoms and CRP. Patient stopped kratom altogether. Clinical symptoms and CRP resolved with no further flares. Prednisone taper was successful without exacerbation of clinical symptoms.

Discussion: We present a UC patient previously in remission on UPA. His clinical recurrence occurred after taking kratom, an herbal opioid agonist. The reinduction of remission required inpatient high dose IFX, AZA and steroid taper. We propose kratom contributed to disease recurrence. Further studies are needed to assess the potential interaction between this bioactive alkaloid and UPA to better inform consumer safety.



Disclosures:


Syed Adeel Hassan, MBBS, MD¹, Ivana Deyl, MD¹, Courtney L. Perry, DO, MS¹, Aaron B. Fein, DO¹, Sai Srikar Venkata, ², Terrence A.. Barrett, MD¹. P2230 - Kratom-Induced Flare of Acute Severe Ulcerative Colitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.