Gastroenterology Elsewhere

STEROIDS AFTER ACUTE SEVERE ULCERATIVE COLITIS CAN BE TAPERED WITHIN 6 WEEKS Alomari M, Chadalavada P, Afraz S. Post-hospitalization short versus long steroid taper strategies in patients with acute severe ulcerative colitis: A comparison of clinical outcomes. Crohns Colitis 360 2024;6:otae025. Acute severe ulcerative colitis (ASUC) is a medical emergency and organ-threatening condition with high mortality in the presteroid era. Steroids are the most commonly used agents, initially as intravenous preparations and later as oral formulations. Societal guidelines on duration of steroid therapy range from 6 weeks to 12 weeks. The authors of this retrospective study, enrolled 215 patients with ASUC for whom steroid was tapered (n = 91) within 6 weeks or longer (n = 124). Forty-six percent of the patients in the longer taper group had a longer duration of disease compared to the shorter taper group (63.8 months vs. 25.6 months, P < 0.0001) and higher endoscopic disease activity index (27.4% vs. 11.0%, P = 0.004). Prior steroid and biologic use and extent of disease were similar in both groups. At the end of 6 months, readmission for ASUC was similar in both groups (65.1% vs. 68.5%, P = 0.723). No difference was noted for increased biologic use, time to new biologic use, or colectomy. On logistic regression, dose escalation within 4 weeks (significantly higher in short taper group) was the only variable associated with readmission for ASUC, which adds incongruity to the results, given that longer taper groups had higher disease activity index. Steroid taper <6 weeks appears to be a reasonable duration, given its unwanted side effects, but randomized, controlled, blinded studies are needed to confirm this. OLEZARSEN'S EFFECT ON FAMILIAL CHYLOMICRONEMIA PANCREATITIS Stroes ES, Alexander VJ, Karwatowska-Prokopczuk E. Olezarsen, acute pancreatitis, and familial chylomicronemia syndrome. N Engl J Med 2024;390:1781-92. Abnormalities in genes encoding for lipoprotein lipase, an enzyme that hydrolyzes triglycerides can result in severe hypertriglyceridemia, which is known as familial chylomicronemia syndrome. Pancreatitis occurs in 85% of these patients, and up to 40% experience recurrences. Fibrates and statins have a limited effect on lowering triglycerides. Researchers in this study test a novel drug olezarsen, an antisense oligonucleotide that binds to apolipoprotein CIII messenger RNA and lowers triglyceride levels. Sixty-six patients with familial chylomicronemia (genetically confirmed) were randomly assigned to receive olezarsen 80 mg or olezarsen 50 mg or placebo subcutaneously every 4 months for up to nearly a year. A significant mean percentage reduction in fasting triglyceride was seen in the 80 mg group compared to placebo; −43.5% points (95% confidence interval, −69.1 to −17.9; P < 0.001). No significant change was seen in the 50 mg group. Eleven episodes of pancreatitis occurred in the placebo group during the study, whereas one episode occurred in the two olezarsen groups. Overall, adverse events were less common with olezarsen than with placebo. The study offers insight into the possibilities of this newer molecule but is limited by the sample size and the continuance of a low-fat diet throughout the study. PATTERNS OF DECOMPENSATION OF CIRRHOSIS AND THEIR IMPACT ON PROGNOSIS Tonon M, D'Ambrosio R, Calvino V. A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis. J Hepatol 2024;80:603-9. Patients with compensated cirrhosis may decompensate over time either acutely or gradually. Authors in this observational study analyze 617 patients (mostly viral and alcohol) with compensated cirrhosis for the patterns and prevalence of decompensation and the impact on survival. Over 5 years, 75% of the patients remained compensated. The rest of the patients either acutely decompensated (AD) (n = 85, 55%) or gradually (n = 69%, 45%). Among the nonacute decompensation (NAD) group, more than a third ended up having acute decompensation subsequently within a year. Model for end-stage liver disease, effective treatment (antivirals or abstinence of alcohol), and prophylactic use of nonselective beta-blockers were found to be independent predictors of decompensation (acute and nonacute) and mortality. The study emphasizes that the pathways for the development of AD and NAD are different. While 1/5 of patients with compensated cirrhosis may develop AD as the index decompensation, NAD also carries a higher risk of AD and, thereby, increased mortality compared to compensated cirrhosis. It is a good exercise to read this study, to have a picture of the natural course of compensated cirrhosis, and a reminder to closely monitor gradually decompensating patients. DOES TISSUE OXYGENATION DETECT INFLAMMATION BETTER IN ULCERATIVE COLITIS? Akiyama S, Sakamoto T, Kobayashi M. Clinical usefulness of hypoxia imaging colonoscopy for the objective measurement of ulcerative colitis disease activity. Gastrointest Endosc 2024;99:1006-16.e4. Inflammation attracts immune-mediated cells, leading to phagocytosis and other cellular events that may result in increased local oxygen and glucose consumption. Authors of this research, use colonic tissue oxygen saturation (StO2) to objectively assess mucosal inflammation in ulcerative colitis (UC). Hypoxia imaging endoscopy is done using a special probe that differentiates oxygenated from deoxygenated hemoglobin at the mucosal layer. Previous studies have estimated that healthy colonic tissue has a StO2 of 40%-70%. One hundred. One hundred patients with UC undergoing colonoscopy were evaluated with a hypoxia probe and compared against clinical, endoscopic, and histologic parameters. Median saturation was significantly highest in tissue with Mayo endoscopy score (MES) of 0 (52%) and progressively declined as the score increased, the least being 39% for MES score of 3. Similar significant findings were seen when saturation was compared with histologic Geboes score 0-2. Regardless, there was no difference in saturation in higher Geboes scores of 3-4. This modern probe may not have a place in clinical practice, as existing scoring systems are good enough. Interestingly, rectal StO2 correlated negatively with clinical scores, especially in the bowel urgency subsection, thereby implicating other factors such as rectal hypersensitivity and compliance playing a role in symptoms. PRACTICE UPDATE ON GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS AND ENDOSCOPY Hashash JG, Thompson CC, Wang AY. AGA rapid clinical practice update on the management of patients taking GLP-1 receptor agonists prior to endoscopy: Communication. Clin Gastroenterol Hepatol 2024;22:705-7. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are being increasingly used in diabetes and the management of obesity. As these drugs are known to slow gastric emptying, overnight fasting alone may not ensure adequate protection from aspiration as evident from recent studies that significant gastric residue is seen in these patients. The same had been confirmed by gastric ultrasound before endoscopy in those taking GLP-1RA in a previous study. In a recent paper presented at DDW 2024 by Phan, the rate of finding retained food on endoscopy (patients taking GLP1-RA, n = 815) was 8.7%, and almost all of them were diabetics (96%). The odds of gastric retention increased as the HbA1C (glycated hemoglobin) increased. The authors in this brief communication recommend withholding the drug before elective endoscopy only in those patients suspected to have delayed gastric emptying and preferably put on a liquid diet, especially in people with diabetes. In those requiring urgent endoscopies, rapid sequence intubation should be considered. These recommendations are in line with the American Society of Anesthesiologists' consensus released in 2023. Financial support and sponsorship Nil Conflicts of interest There are no conflicts of interest.