University of Kentucky College of Medcine Lexington, KY, United States
Award: Presidential Poster Award
Aaron Brenner, MD1, Patrick J. Carey, MD1, Terrence A. Barrett, MD2, Nancy Mannon, RPH1, Casie Mayne, PA-C2, Karen Ingram, RN1 1University of Kentucky College of Medcine, Lexington, KY; 2University of Kentucky, Lexington, KY
Introduction: Refractory collagenous colitis can severely limit a patient’s quality of life. Ustekinumab can provide a viable treatment option, with evidence of symptom remission and biomarker reduction.
Case Description/Methods: A 64-year-old Caucasian male with Celiac disease and collagenous colitis presented in clinic for persistent diarrhea and unintentional weight loss. Celiac disease was diagnosed at age 55 and controlled with a gluten-free diet. tTG-IgA, DGA-IgA and EmA have been normal for multiple years. Since being diagnosed with collagenous colitis at age 59, he has had loose stools over 10 times a day, severely impacting his quality of life. He lost > 10 pounds and complains of fatigue.
Initial treatment with oral budesonide 9mg/d and loperamide yielded mild improvement. Attempts to taper led to worsening diarrhea and weight loss. He was trialed on vedolizumab every 8 weeks plus daily budesonide, which initially stabilized his fecal calprotectin and CRP, as well decreased stools (2-4 loose BMs daily). However, he was unable to gain weight.
After 2 years on vedolizumab, daily BMs became difficult to control and his inflammatory markers increased. He transitioned from vedolizumab to ustekinumab (infusion then 90mg injections every 8 weeks) and budesonide 9mg/d. His initial response persisted for one year and now he is averaging 1-2 formed stools daily with a 12 lb weight gain. CRP (2.7 to < 0.3) and fecal calprotectin (1225 to 93) also improved significantly.
Discussion: First line therapy for collagenous colitis is an 8-week course of budesonide. After the 8-week course, between 40-81% of patients relapse (Munch, et al. Gut 2014). Long term budesonide therapy poses serious side effects: immunosuppression, HPA axis suppression, sodium retention, insomnia, and myopathy. Ustekinumab, an IL-12 and IL-23 inhibitor, is currently approved for use in psoriasis, UC, and Crohn’s disease. IL-12 and IL-23 are pro-inflammatory cytokines that promote differentiation of T-helper cells.
Given that the collagenous colitis is driven by T-helper type 1 inflammatory responses, we propose ustekinumab to be a safe and effective therapy for cases that do not achieve remission with budesonide alone. In this patient, ustekinumab in combination with budesonide was successful in achieving clinical remission and reduction in inflammatory.
Munch et al. Low-dose budesonide for maintenance of clinical remission in collagenous colitis: a randomised, placebo-controlled, 12-month trial Gut. 2014.
Aaron Brenner indicated no relevant financial relationships.
Patrick Carey indicated no relevant financial relationships.
Terrence Barrett indicated no relevant financial relationships.
Nancy Mannon indicated no relevant financial relationships.
Casie Mayne indicated no relevant financial relationships.
Karen Ingram indicated no relevant financial relationships.
Aaron Brenner, MD1, Patrick J. Carey, MD1, Terrence A. Barrett, MD2, Nancy Mannon, RPH1, Casie Mayne, PA-C2, Karen Ingram, RN1. P1679 - Remission of Sprue-Associated Collagenous Colitis With Ustekinumab, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.