Scandinavian Journal of Gastroenterology. 2014; 49: 418–423
ORIGINAL ARTICLE
The correlation between fecal calprotectin, simple clinical colitis activity index and biochemical markers in ulcerative colitis during high-dose steroid treatment
KLAUS THEEDE, MARIANNE KISZKA-KANOWITZ, ANETTE MERTZ NIELSEN & INGE NORDGAARD-LASSEN Gastrounit, Medical Division 360, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
Abstract Objective. Monitoring active ulcerative colitis (UC) is essential for making correct and timely treatment decisions. The current monitoring is based on symptom scores and biochemical markers, among which the role of fecal calprotectin (FC) is debated. The aims were to assess the development in FC during steroid treatment and to compare FC with symptom scores and biochemical markers. Material and methods. A prospective observational study, including 16 patients with active UC requiring high-dose steroid treatment. FC, C-reactive protein (CRP), leukocytes, hemoglobin, albumin, and simple clinical colitis activity index (SCCAI) were assessed before the initiation of treatment, as well as on days 2, 6, 13, and 27. The one-year follow-up data were retrospectively obtained. Results. All patients had significant decreasing levels of FC (–1014 mg/kg, p = 0.0061), CRP (–10 mmol/l, p = 0.0313), and SCCAI (–3, p = 0.0002) during the first 4 days. After 27 days, the FC had decreased to 216 mg/kg (p = 0.002). A significant correlation between the changes in CRP and SCCAI was found (rs = 0.65, p = 0.03) but not between FC and CRP or SCCAI. Overall, significant correlations between absolute levels of FC, CRP, and SCCAI were found. Levels of FC on day 0 and day 4 were not predictive of sustained clinical remission at 1-year follow up. Conclusions. FC, CRP, and SCCAI seem to be reliable markers of treatment response during steroid treatment. High initial levels of FC and a subsequent rapid reduction during steroid treatment were identified. FC levels were not found to be predictive of disease prognosis after one year.
Key Words: disease monitoring, fecal calprotectin, inflammatory bowel disease, ulcerative colitis
Introduction Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by recurrent episodes of inflammation in the colonic mucosa. In periods of active disease, medical therapy is needed, and in cases of moderate-to-severe inflammation, corticosteroid therapy is often necessary. The evaluation of disease severity is based on a combination of the clinical assessment of the patient’s symptoms, biochemical markers, and endoscopy. A majority of the morbidity due to IBD s is observed in patients with severe active UC. Up to 20–30% of patients with acute severe UC fail to
respond to medical treatment and require an urgent colectomy [1,2]. It is important to monitor these patients closely and to evaluate their responses to steroid treatment. The nonresponding patients are offered either second-line rescue therapy with infliximab or calcineurin inhibitors, or eventually, colectomy. Failure to identify the nonresponders within an appropriate time frame leads to increased morbidity and eventual mortality. Different prognostic models that are useful in identifying nonresponding patients have been developed, but these are used infrequently in daily practice and rely mostly on subjective clinical parameters [2,3].
Correspondence: Klaus Theede, Gastrounit, Medical Division 360, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Denmark. Tel: +45 38621863; Fax: +45 38623777. E-mail: [email protected]
(Received 2 December 2013; revised 9 January 2014; accepted 9 January 2014) ISSN 0036-5521 print/ISSN 1502-7708 online 2014 Informa Healthcare DOI: 10.3109/00365521.2014.883427
FC in active UC Usually, biochemical blood markers are used, but studies have shown that the sensitivity, specificity, and correlation to disease activity are low [4]. Endoscopy is accurate in the assessment of disease activity and disease extent, but it is inconvenient to repeat too often. Therefore, there is a need to develop and test new markers that are accurate and reliable in monitoring disease activity and treatment response. Fecal calprotectin (FC) is a protein found in large concentrations in the cytosol of neutrophilic leukocytes. Significant differences in the levels of FC in patients with active and inactive disease have been found in several studies [5,6]. FC has been shown to correlate well with disease activity and the grade of mucosal inflammation, assessed both endoscopically and histologically [4,7,8]. The use of a single FC measurement in the beginning of the treatment for predicting the clinical course of acute severe UC has been studied, and the level was shown to be significantly higher in patients requiring colectomy, with a trend toward higher levels in both steroid and infliximab nonresponders [2]. These results led to the hypothesis that FC might be useful in monitoring disease activity and treatment response and in predicting outcomes for patients with active UC. In this prospective observational study, we measured the correlations among FC, symptom scores, and biochemical markers in patients with UC during steroid treatment. Furthermore, we evaluated whether these parameters could predict treatment outcomes. Materials and methods All patients were recruited from the Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre in Denmark. The study was approved by the Regional Committee on Health Research Ethics and the Danish Data Protection Agency. All subjects signed an informed consent form prior to enrolment. Patients were identified during admission to the department ward or in the outpatient clinic and included if they were about to begin a high-dose steroid treatment for active UC. The decision to initiate steroid therapy was unrelated to the study protocol and was made by the department’s gastroenterologists. Patients received treatment with oral prednisolone 75/50 mg/day, for hospitalized/outpatients, respectively. Patients receiving 75 mg were tapered off to 50 mg when a definite clinical response was observed. Both groups were subsequently tapered off by 5 mg once a week. Stool samples (FC) and blood samples (leukocytes, hemoglobin, albumin, and C-reactive protein [CRP]) were collected at days 0, 2, 4, 6, 13,
419
and 27, and calculations of the simple clinical colitis activity index (SCCAI) were made [9]. The stool sample to be analyzed for the concentration of calprotectin was collected on the day of treatment initiation but before the first steroid administration. SCCAI measures stool frequency at day and night, urgency, rectal bleeding, general well-being and extra-intestinal manifestations. Values for each parameter were added for a total score. As the patients did not have to show up at the hospital at all the sampling days, they were instructed in self-assessment of symptoms using SCCAI, which is a complete self-assessment tool. A SCCAI score of ‡6 was considered moderate-tosevere active disease [10]. Patients were followed for 27 days, and 1-year follow-up data were retrospectively obtained from the patients’ records. FC levels and SCCAI values were collected concurrently with the treatment and were not available in the clinical assessment of disease activity. Evaluation of the treatment response was made at day 4–5 (after 3 complete days of steroid treatment) and was based on global physician assessment and retrospectively on decreasing SCCAI score. Sustained clinical remission was defined as clinical remission from day 27 and during one year and was based on the absence of symptoms and no need for changing treatment modality or dose escalation. Relapse was defined as recurrence of symptoms requiring change of treatment modality or dose escalation from day 27 and during one year. FC was analyzed using a PhiCal ELISA test from CalPro AS. The assay kit has an upper limit at 3600 mg/kg, so the stool samples were diluted to obtain absolute values of calprotectin above this limit. Data were analyzed using nonparametric statistics. To compare changes in the individual parameters, the Wilcoxon rank-sum test and Wilcoxon–Mann–Whitney test were used. Correlations among parameters were assessed by Spearman correlation. Sensitivity and specificity for FC to predict the treatment outcome were calculated using receiver-operating-curve (ROC) analysis. Data were analyzed using SAS Enterprise Guide 5.1 (SAS Institute Inc., Cary, NC, USA). Results In total, 17 patients were included in the study, of which one patient was subsequently excluded, as biopsies from the colon were compatible with Crohn’s disease. The baseline characteristics are shown in Table I. Three patients had their first episode of UC. All of them initiated treatment with aminosalicylates during steroid treatment; 13 patients were previously diagnosed with UC. Prior to enrolment, 10 patients
420
K. Theede et al.
Table I. Patient characteristics. n = 16
Characteristics Age (median, range) Gender (male/female) Disease duration (median/range) Disease location Proctosigmoiditis Left-sided colitis Extensive colitis Smoking Never Former Current Prednisolone oral 75/50 mg Hospitalized/Outpatient
35 years (22–66) 9/7 24 weeks (1–168) 3 1 12 12 3 1 13/3 14/2
received aminosalicylates, 1 received azathioprine and 2 received no treatment. All patients primarily responded to the steroid therapy. In total, six patients went into sustained clinical remission and two patients had only a partial response to steroid treatment. They received infliximab during the steroid course and went into clinical remission. Eight patients with a primary response to steroid treatment relapsed during the first year and initiated concomitant therapy with azathioprine and aminosalicylate combo, with increased doses of aminosalicylates alone or steroids based on the clinical setting and prior medication. One patient underwent colectomy during the first year. Table II shows the median values and interquartile ranges (IQRs) for SCCAI, FC, and biochemical markers during the study period. According to the SCCAI values on day 0, nine patients were considered as having moderate or severely active disease. Patients with known extensive colitis had an initial median FC of 3390 mg/kg, but this was not significantly higher than the group with proctosigmoiditis or left-sided colitis, with an initial median FC of 1518 mg/kg, p = 0.71.
In the first 4 days, all patients had decreasing levels of FC and SCCAI, and 66% had decreasing levels of CRP. An expected significant increase in leukocytes was found, but no significant changes in hemoglobin or albumin were observed (see Table III). After 27 days, the FC had decreased to a median value of 216 mg/kg (IQR: 49–1490 mg/kg, p = 0.002) compared to baseline. The levels of calprotectin for all of the patients during the study period can be found in Figure 1. We found a significant correlation between CRP and SCCAI (rs = 0.65, p = 0.03), but not between FC and SCCAI (rs = –0.06, p = 0.83) or FC and CRP (rs = 0.56, p = 0.12), during the first 4 days. Overall, during the study, we found significant correlation between levels of FC and CRP (rs = 0.46, p < 0.0001), between FC and SCCAI (rs = 0.36, p = 0.001), and between CRP and SCCAI (rs = 0.28, p = 0.01). Patients who achieved sustained clinical remission had initial median FC levels of 4237 mg/kg, and the patients who were either partial responders or relapsed during the first year had initial median FC level of 2003 mg/kg. The difference was not significant, p = 0.24. If we looked only at relapses, the initial levels of FC showed no significant difference between patients with sustained remission and patients who relapsed (FC 4237/2003 mg/kg, p = 0.25). The patients who relapsed had a median FC of 44 mg/kg on day 27 compared to the patients who achieved sustained clinical remission with FC of median 375 mg/kg. The difference was not significant (p = 0.17). The change in FC from day 0 to day 4 (DFC) was not significantly different between the patients with sustained clinical remission and those who relapsed (DFC –6259/–873 mg/kg, p = 0.22). We calculated ROCs to see if levels of FC at day 0 or at day 4 could predict sustained clinical remission. The ROC analysis for day 0 gave an AUC of
Table II. Laboratory parameters. Day SCCAI (median,IQR) Calprotectin (
ORIGINAL ARTICLE
The correlation between fecal calprotectin, simple clinical colitis activity index and biochemical markers in ulcerative colitis during high-dose steroid treatment
KLAUS THEEDE, MARIANNE KISZKA-KANOWITZ, ANETTE MERTZ NIELSEN & INGE NORDGAARD-LASSEN Gastrounit, Medical Division 360, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
Abstract Objective. Monitoring active ulcerative colitis (UC) is essential for making correct and timely treatment decisions. The current monitoring is based on symptom scores and biochemical markers, among which the role of fecal calprotectin (FC) is debated. The aims were to assess the development in FC during steroid treatment and to compare FC with symptom scores and biochemical markers. Material and methods. A prospective observational study, including 16 patients with active UC requiring high-dose steroid treatment. FC, C-reactive protein (CRP), leukocytes, hemoglobin, albumin, and simple clinical colitis activity index (SCCAI) were assessed before the initiation of treatment, as well as on days 2, 6, 13, and 27. The one-year follow-up data were retrospectively obtained. Results. All patients had significant decreasing levels of FC (–1014 mg/kg, p = 0.0061), CRP (–10 mmol/l, p = 0.0313), and SCCAI (–3, p = 0.0002) during the first 4 days. After 27 days, the FC had decreased to 216 mg/kg (p = 0.002). A significant correlation between the changes in CRP and SCCAI was found (rs = 0.65, p = 0.03) but not between FC and CRP or SCCAI. Overall, significant correlations between absolute levels of FC, CRP, and SCCAI were found. Levels of FC on day 0 and day 4 were not predictive of sustained clinical remission at 1-year follow up. Conclusions. FC, CRP, and SCCAI seem to be reliable markers of treatment response during steroid treatment. High initial levels of FC and a subsequent rapid reduction during steroid treatment were identified. FC levels were not found to be predictive of disease prognosis after one year.
Key Words: disease monitoring, fecal calprotectin, inflammatory bowel disease, ulcerative colitis
Introduction Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by recurrent episodes of inflammation in the colonic mucosa. In periods of active disease, medical therapy is needed, and in cases of moderate-to-severe inflammation, corticosteroid therapy is often necessary. The evaluation of disease severity is based on a combination of the clinical assessment of the patient’s symptoms, biochemical markers, and endoscopy. A majority of the morbidity due to IBD s is observed in patients with severe active UC. Up to 20–30% of patients with acute severe UC fail to
respond to medical treatment and require an urgent colectomy [1,2]. It is important to monitor these patients closely and to evaluate their responses to steroid treatment. The nonresponding patients are offered either second-line rescue therapy with infliximab or calcineurin inhibitors, or eventually, colectomy. Failure to identify the nonresponders within an appropriate time frame leads to increased morbidity and eventual mortality. Different prognostic models that are useful in identifying nonresponding patients have been developed, but these are used infrequently in daily practice and rely mostly on subjective clinical parameters [2,3].
Correspondence: Klaus Theede, Gastrounit, Medical Division 360, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Denmark. Tel: +45 38621863; Fax: +45 38623777. E-mail: [email protected]
(Received 2 December 2013; revised 9 January 2014; accepted 9 January 2014) ISSN 0036-5521 print/ISSN 1502-7708 online 2014 Informa Healthcare DOI: 10.3109/00365521.2014.883427
FC in active UC Usually, biochemical blood markers are used, but studies have shown that the sensitivity, specificity, and correlation to disease activity are low [4]. Endoscopy is accurate in the assessment of disease activity and disease extent, but it is inconvenient to repeat too often. Therefore, there is a need to develop and test new markers that are accurate and reliable in monitoring disease activity and treatment response. Fecal calprotectin (FC) is a protein found in large concentrations in the cytosol of neutrophilic leukocytes. Significant differences in the levels of FC in patients with active and inactive disease have been found in several studies [5,6]. FC has been shown to correlate well with disease activity and the grade of mucosal inflammation, assessed both endoscopically and histologically [4,7,8]. The use of a single FC measurement in the beginning of the treatment for predicting the clinical course of acute severe UC has been studied, and the level was shown to be significantly higher in patients requiring colectomy, with a trend toward higher levels in both steroid and infliximab nonresponders [2]. These results led to the hypothesis that FC might be useful in monitoring disease activity and treatment response and in predicting outcomes for patients with active UC. In this prospective observational study, we measured the correlations among FC, symptom scores, and biochemical markers in patients with UC during steroid treatment. Furthermore, we evaluated whether these parameters could predict treatment outcomes. Materials and methods All patients were recruited from the Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre in Denmark. The study was approved by the Regional Committee on Health Research Ethics and the Danish Data Protection Agency. All subjects signed an informed consent form prior to enrolment. Patients were identified during admission to the department ward or in the outpatient clinic and included if they were about to begin a high-dose steroid treatment for active UC. The decision to initiate steroid therapy was unrelated to the study protocol and was made by the department’s gastroenterologists. Patients received treatment with oral prednisolone 75/50 mg/day, for hospitalized/outpatients, respectively. Patients receiving 75 mg were tapered off to 50 mg when a definite clinical response was observed. Both groups were subsequently tapered off by 5 mg once a week. Stool samples (FC) and blood samples (leukocytes, hemoglobin, albumin, and C-reactive protein [CRP]) were collected at days 0, 2, 4, 6, 13,
419
and 27, and calculations of the simple clinical colitis activity index (SCCAI) were made [9]. The stool sample to be analyzed for the concentration of calprotectin was collected on the day of treatment initiation but before the first steroid administration. SCCAI measures stool frequency at day and night, urgency, rectal bleeding, general well-being and extra-intestinal manifestations. Values for each parameter were added for a total score. As the patients did not have to show up at the hospital at all the sampling days, they were instructed in self-assessment of symptoms using SCCAI, which is a complete self-assessment tool. A SCCAI score of ‡6 was considered moderate-tosevere active disease [10]. Patients were followed for 27 days, and 1-year follow-up data were retrospectively obtained from the patients’ records. FC levels and SCCAI values were collected concurrently with the treatment and were not available in the clinical assessment of disease activity. Evaluation of the treatment response was made at day 4–5 (after 3 complete days of steroid treatment) and was based on global physician assessment and retrospectively on decreasing SCCAI score. Sustained clinical remission was defined as clinical remission from day 27 and during one year and was based on the absence of symptoms and no need for changing treatment modality or dose escalation. Relapse was defined as recurrence of symptoms requiring change of treatment modality or dose escalation from day 27 and during one year. FC was analyzed using a PhiCal ELISA test from CalPro AS. The assay kit has an upper limit at 3600 mg/kg, so the stool samples were diluted to obtain absolute values of calprotectin above this limit. Data were analyzed using nonparametric statistics. To compare changes in the individual parameters, the Wilcoxon rank-sum test and Wilcoxon–Mann–Whitney test were used. Correlations among parameters were assessed by Spearman correlation. Sensitivity and specificity for FC to predict the treatment outcome were calculated using receiver-operating-curve (ROC) analysis. Data were analyzed using SAS Enterprise Guide 5.1 (SAS Institute Inc., Cary, NC, USA). Results In total, 17 patients were included in the study, of which one patient was subsequently excluded, as biopsies from the colon were compatible with Crohn’s disease. The baseline characteristics are shown in Table I. Three patients had their first episode of UC. All of them initiated treatment with aminosalicylates during steroid treatment; 13 patients were previously diagnosed with UC. Prior to enrolment, 10 patients
420
K. Theede et al.
Table I. Patient characteristics. n = 16
Characteristics Age (median, range) Gender (male/female) Disease duration (median/range) Disease location Proctosigmoiditis Left-sided colitis Extensive colitis Smoking Never Former Current Prednisolone oral 75/50 mg Hospitalized/Outpatient
35 years (22–66) 9/7 24 weeks (1–168) 3 1 12 12 3 1 13/3 14/2
received aminosalicylates, 1 received azathioprine and 2 received no treatment. All patients primarily responded to the steroid therapy. In total, six patients went into sustained clinical remission and two patients had only a partial response to steroid treatment. They received infliximab during the steroid course and went into clinical remission. Eight patients with a primary response to steroid treatment relapsed during the first year and initiated concomitant therapy with azathioprine and aminosalicylate combo, with increased doses of aminosalicylates alone or steroids based on the clinical setting and prior medication. One patient underwent colectomy during the first year. Table II shows the median values and interquartile ranges (IQRs) for SCCAI, FC, and biochemical markers during the study period. According to the SCCAI values on day 0, nine patients were considered as having moderate or severely active disease. Patients with known extensive colitis had an initial median FC of 3390 mg/kg, but this was not significantly higher than the group with proctosigmoiditis or left-sided colitis, with an initial median FC of 1518 mg/kg, p = 0.71.
In the first 4 days, all patients had decreasing levels of FC and SCCAI, and 66% had decreasing levels of CRP. An expected significant increase in leukocytes was found, but no significant changes in hemoglobin or albumin were observed (see Table III). After 27 days, the FC had decreased to a median value of 216 mg/kg (IQR: 49–1490 mg/kg, p = 0.002) compared to baseline. The levels of calprotectin for all of the patients during the study period can be found in Figure 1. We found a significant correlation between CRP and SCCAI (rs = 0.65, p = 0.03), but not between FC and SCCAI (rs = –0.06, p = 0.83) or FC and CRP (rs = 0.56, p = 0.12), during the first 4 days. Overall, during the study, we found significant correlation between levels of FC and CRP (rs = 0.46, p < 0.0001), between FC and SCCAI (rs = 0.36, p = 0.001), and between CRP and SCCAI (rs = 0.28, p = 0.01). Patients who achieved sustained clinical remission had initial median FC levels of 4237 mg/kg, and the patients who were either partial responders or relapsed during the first year had initial median FC level of 2003 mg/kg. The difference was not significant, p = 0.24. If we looked only at relapses, the initial levels of FC showed no significant difference between patients with sustained remission and patients who relapsed (FC 4237/2003 mg/kg, p = 0.25). The patients who relapsed had a median FC of 44 mg/kg on day 27 compared to the patients who achieved sustained clinical remission with FC of median 375 mg/kg. The difference was not significant (p = 0.17). The change in FC from day 0 to day 4 (DFC) was not significantly different between the patients with sustained clinical remission and those who relapsed (DFC –6259/–873 mg/kg, p = 0.22). We calculated ROCs to see if levels of FC at day 0 or at day 4 could predict sustained clinical remission. The ROC analysis for day 0 gave an AUC of
Table II. Laboratory parameters. Day SCCAI (median,IQR) Calprotectin (
