title: Prevalence and Risk Factors for Therapy Escalation in Ulcerative Colitis in the Swiss IBD Cohort Study.
abstract: BACKGROUND
  Physicians traditionally treat ulcerative colitis (UC) using a step-up approach. Given the paucity of data, we aimed to assess the cumulative probability of UC-related need for step-up therapy and to identify escalation-associated risk factors.
  
  
  METHODS
  Patients with UC enrolled into the Swiss IBD Cohort Study were analyzed. The following steps from the bottom to the top of the therapeutic pyramid were examined: (1) 5-aminosalicylic acid and/or rectal corticosteroids, (2) systemic corticosteroids, (3) immunomodulators (IM) (azathioprine, 6-mercaptopurine, methotrexate), (4) TNF antagonists, (5) calcineurin inhibitors, and (6) colectomy.
  
  
  RESULTS
  Data on 996 patients with UC with a median disease duration of 9 years were examined. The point estimates of cumulative use of different treatments at years 1, 5, 10, and 20 after UC diagnosis were 91%, 96%, 96%, and 97%, respectively, for 5-ASA and/or rectal corticosteroids, 63%, 69%, 72%, and 79%, respectively, for systemic corticosteroids, 43%, 57%, 59%, and 64%, respectively, for IM, 15%, 28%, and 35% (up to year 10 only), respectively, for TNF antagonists, 5%, 9%, 11%, and 12%, respectively, for calcineurin inhibitors, 1%, 5%, 9%, and 18%, respectively, for colectomy. The presence of extraintestinal manifestations and extended disease location (at least left-sided colitis) were identified as risk factors for step-up in therapy with systemic corticosteroids, IM, TNF antagonists, calcineurin inhibitors, and surgery. Cigarette smoking at diagnosis was protective against surgery.
  
  
  CONCLUSIONS
  The presence of extraintestinal manifestations, left-sided colitis, and extensive colitis/pancolitis at the time of diagnosis were associated with use of systemic corticosteroids, IM, TNF antagonists, calcineurin inhibitors, and colectomy during the disease course.
authors: *Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; †Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland; ‡Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland; §Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland; ‖Division of Gastroenterology and Hepatology, University Hospital Basel, Basel, Switzerland; and ¶Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland.
authors: Ekaterina
authors: E
authors: Safroneeva
authors: Stephan R
authors: SR
authors: Vavricka
authors: Nicolas
authors: N
authors: Fournier
authors: Alex
authors: A
authors: Straumann
authors: Gerhard
authors: G
authors: Rogler
authors: Alain M
authors: AM
authors: Schoepfer
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D065095:Calcineurin Inhibitors / Q000627:therapeutic use; D015331:Cohort Studies; D003082:Colectomy / Q000706:statistics & numerical data; D003093:Colitis, Ulcerative / Q000473:pathology / Q000628:therapy*; D018450:Disease Progression; D005260:Female; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use; D008297:Male; D019804:Mesalamine / Q000627:therapeutic use; D008875:Middle Aged; D019233:Retreatment; D012307:Risk Factors; D012907:Smoking; D013557:Switzerland; D013997:Time Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D000894:Anti-Inflammatory Agents, Non-Steroidal; D065095:Calcineurin Inhibitors; D007155:Immunologic Factors; D014409:Tumor Necrosis Factor-alpha; D019804:Mesalamine