According to data from the Crohn’s & Colitis Foundation of America, ulcerative colitis (UC) is an inflammatory bowel disease that affects up to 700,000 Americans. Current medications that are used for UC—which often include corticosteroids or long-term immunosuppressant therapy—do not lead to remission for all patients, and relapse rates are high even among those who achieve remission using medical therapies.
“While medical therapy is generally safe for people with UC, only about one-third of patients experience a long-term response to medications,” explains Meenakshi Bewtra, MD, MPH, PhD. Patients also must endure a trial-and-error approach until they find a medication that works for them, which can severely impact quality of life (QOL). In addition, some UC medications come with higher risks of serious side effects.
As an alternative to medical therapy, patients with UC can undergo elective colectomy, a surgery which involves performing a total proctocolectomy with ileostomy and, in many cases, restorative ileal pouch anal anastomosis. “Surgery has always been an option for patients with UC, but it is often viewed as a last resort,” says Dr. Bewtra. Research shows that elective colectomy is associated with low morbidity and mortality, but it may also alter patients’ QOL following the procedure.
QOL, morbidity, and mortality are important factors that drive treatment decisions for patients with UC and their physicians. Dr. Bewtra and colleagues had a retrospective study published in Annals of Internal Medicine that looked at whether or not patients with advanced UC had better survival by undergoing elective colectomy or by being treated with medical therapy. “It’s important to clarify if elective surgery for UC can improve survival,” says Dr. Bewtra.
For the study, the research team used national Medicare and Medicaid data to examine whether patients with advanced UC who pursued elective colectomy had improved survival when they were compared with similar patients who elected to use chronic medical therapy. The investigators followed 830 patients who had elective colectomy matched to 7,541 patients who took medications to manage advanced UC. The primary outcome was time to death, and all operations were performed between 2000 and 2011.
Surgery Trumps Medications
According to the results, the mortality rate associated with elective surgery was significantly lower than that of patients who received medical therapy (Table). Elective colectomy was associated with improved survival when compared with long-term medical therapy (adjusted hazard ratio, 0.67).
“Importantly, our analysis showed that the survival benefit from elective colectomy was greatest for those aged 50 and older who had advanced disease,” Dr. Bewtra says. “It is often assumed that older patients have an increased risk of death as a result of complications from surgery, but this did not appear to be the case.” Over 5 years, surgery was linked to a 33% reduced risk of death when compared with medical therapy.
Analyzing the Implications
Findings from study have important implications for both patients and providers with regards to informed decision making in UC, according to Dr. Bewtra. “Traditionally, clinicians have assumed that patients with advanced UC will want to avoid colectomy because of concerns about QOL after the procedure,” she says. “This leads many clinicians to not initiate discussions about surgical options in UC or only discuss it when all other medical therapies have failed. Our study suggests that surgery should be considered earlier in the course of the disease rather than seen as a last resort.”
Recent studies have shown that UC patients appear to be willing to accept surgery in order to avoid potential adverse effects of chronic immunosuppressant therapies, especially if these medications are not completely effective in maintaining remission. “The decision to opt for surgery should be made on a case-by-case basis, keeping in mind the wishes of patients,” says Dr. Bewtra. “However, patients should be educated about surgical options earlier in their disease course. They should also be informed that surgery is likely to improve survival and offers the added benefit of avoiding failed medical therapy.” Elective colectomy is typically covered by Medicare and other health plans.
The finding of a survival advantage with elective colectomy in patients aged 50 or older underscores the need for earlier and more informed discussions regarding surgical options in UC. “These conversations are critical to improving shared decision-making,” Dr. Bewtra says. She notes that it may behoove clinicians to refer patients to specialists if there are any questions or concerns about which therapeutic strategy to select. In addition, efforts should be made to discuss the possibility that corticosteroid use or incompletely controlled UC may increase the risk of death.
Bewtra M, Newcomb CW, Wu Q, et al. Mortality associated with medical therapy versus elective colectomy in ulcerative colitis: a cohort study. Ann Intern Med. 2015 Jul 14 [Epub ahead of print]. Available at: http://annals.org/article.aspx?articleid=2395724.
Sachar DB. Ulcerative colitis: dead or alive. Ann Intern Med. 2015 Jul 14 [Epub ahead of print].
Lewis JD, Gelfand JM, Troxel AB, et al. Immunosuppressant medications and mortality in inflammatory bowel disease. Am J Gastroenterol. 2008;103:1428-1435.
Kaplan GG, Lim A, Seow CH, et al. Colectomy is a risk factor for venous thromboembolism in ulcerative colitis. World J Gastroenterol. 2015;21:1251-1260.