Exploring the ACE Index in Acute Ulcerative Colitis

Dr. Figueroa:
For ReachMD, this is Audio Abstracts, produced in collaboration with the Crohn's & Colitis Foundation.  I'm Dr. Esteban Figueroa, and I'm an Assistant Professor of Medicine in the Division of Gastroenterology in the Department of Medicine at the University of Virginia.  I'm also a member of the Crohn's & Colitis Foundation's Rising Educators Academics and Clinicians Helping IBD group, or REACH-IBD. 

Today I have the pleasure of reviewing an article published in the Inflammatory Bowel DiseaseJournal titled, “The ACE (Albumin, CRP and Endoscopy) Index in Acute Colitis: A Simple Clinical Index on Admission that Predicts Outcomes in Patients with Acute Ulcerative Colitis.”  This study was conducted by the Edinburgh IBD Unit in collaboration with the Translational Gastrointestinal Unit at John Radcliffe Hospital in Oxford, UK. 

As background, approximately 20% of patients with ulcerative colitis, or UC for short, will experience at least 1 severe acute exacerbation requiring hospitalization.  Acute severe UC is traditionally defined by the Truelove and Witts criteria as bloody stool frequency of 6 or more a day plus at least 1 other marker of systemic disturbance, such as anemia, elevated erythrocyte sedimentation rate or C-reactive protein, fever, and tachycardia.  Acute severe UC carries a significant risk for colectomy.  The first line for treatment of acute severe UC is IV steroids.  However, the rate of IV steroid nonresponse can reach 30% in acute severe UC and 20% in hospitalized patients with acute UC who do not meet criteria for acute severe ulcerative colitis. 

We currently have multiple clinical scoring systems that define steroid nonresponse on day 3 of IV steroids but not prior to administration.  Therefore, early prognostication is essential in both acute severe UC and acute UC requiring hospitalization, and that is why I find this article noteworthy.  With this study, the Edinburgh IBD Unit aimed to identify clinical and endoscopic parameters collected at the beginning of a patient's hospital course which could predict nonresponse to IV steroids in both acute severe and nonsevere UC.  Acute nonsevere UC was defined as either less than 6 stools per day or greater than 6 stools per day without rectal bleeding or without systemic disturbance as per the Truelove and Witts criteria. 

In this multicenter retrospective cohort study, 235 acute UC admissions were identified.  Across the entire cohort, 66% responded to IV steroids.  Admission values for C-reactive protein, albumin, and endoscopic severity defined as using the Mayo Endoscopic Score were found to be significant predictors of nonresponse to IV steroids.  The authors developed a simple clinical scoring system called the ACE Index, which ranges from 0 to 3, utilizing these clinical parameters.  More than three-quarters of patients with an ACE score of 3 did not respond to IV steroids. 

In summary, this study reports a novel, simple clinical scoring index that can be used at time of admission in acute UC.  Additionally, early prognostication may help patients by initiating earlier discussions regarding rescue medical therapy or surgical intervention.  However, it's important to note the limitations of this study, which include its retrospective nature, small sample size, and low prevalence of patients being treated with a biologic or prior treatment with biologic.  Considering these limitations, the study's results may not be generalizable to patients treated with biologics, and the authors recommend that these results be independently validated. 

If you're interested in this topic or others on Crohn's disease or ulcerative colitis, the Crohn's & Colitis Foundation's Inflammatory Bowel Disease Journal provides the most impactful and cutting-edge clinical topics and research findings.  For more information on the foundation, please visit CrohnsColitisFoundation.org. 

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