Intestinal Ultrasound to Assess Clinical Response After Induction With Upadacitinib in Acute Severe Ulcerative Colitis

Background: Intestinal ultrasound (IUS) is a noninvasive and cost-effective tool to determine disease activity in ulcerative colitis (UC). Upadacitinib (UPA) has been shown to be effective in moderate to severe UC however, data is lacking for acute severe UC (ASUC). This case report is the first to show treatment response assessed by IUS after induction with UPA in a patient with ASUC. Materials: A 19-year-old male with a history of UC presented to the hospital with 10-15 bloody bowel movements daily for 2 weeks, despite dose escalation of infliximab one month prior due to low drug level < 0.4 ug/mL and anti-infliximab antibody level of 27 ng/mL after 3 months of treatment. His labs were notable for albumin 3.5 gm/dL, ferritin of 10 ng/mL, Hg 6.4 gm/dL, CRP 2.61 mg/L. Clostridioides difficile testing and serum CMV PCR negative. Results: Flexible sigmoidoscopy on day 3 showed ulcerations with marked erythema and friability in the rectosigmoid colon with Mayo endoscopic subscore 3. Biopsies returned negative for CMV. IUS showed diffusely thickened sigmoid colon wall (6.5 mm) with increased vascularity (Limberg score grade 3) consistent with ASUC. Patient was started on intravenous steroids. Despite IV steroids, he continued to have daily 5-10 bowel movements with blood, urgency, and abdominal pain with rising CRP to 6.03 mg/L. Patient was started on UPA 45 mg daily. Over the next 4 days, patient’s bowel movements decreased to < 5 per day without blood or urgency and was transitioned to prednisone 40 mg daily. On the fifth day of Upadacitinib treatment, a repeat IUS was performed and showed interval significant improvement in the mural thickening and vascularity of the sigmoid colon (3.5 mm and Limberg score grade 1, respectively) suggestive of treatment response. He was subsequently discharged home on a prednisone taper and UPA 45 mg daily. At follow-up in clinic after 5 weeks from hospital discharge, his weight had increased from 127 to 149 pounds, he was experiencing a clinical remission and down to 15mg prednisone daily. At 3 month follow up he was in steroid free clinical remission. Conclusions: UPA is effective in achieving rapid clinical response assessed by improvement in the bowel wall thickness and vascularity on IUS in a patient with ASUC. This case report is the first to show treatment response after induction with UPA in a patient with ASUC with IUS as an objective tool, offering an additional non-invasive, cost-effective method for monitoring disease activity as well as an alternative salvage treatment in those with ASUC who fail anti-TNF medications. Further prospective studies are needed to assess effectiveness of UPA in ASUC as well as IUS monitoring in this population.