Ulcerative colitis in Madrid, Spain: Current management

To the Editor: We read with great interest the study by Barreiro et al.1 It provides valuable information about the current status of ulcerative colitis (UC), in particular about its medical management. Few studies address this issue in UC, an interesting issue in understanding the current practice in inflammatory bowel disease (IBD) and the role of new and old treatments. The present study completes the picture painted by Barreiro et al. Hospital Fundación Alcorcón is a tertiary hospital in southwest Madrid (in the middle of Spain). It provides assistance to 19 municipalities and 264,000 inhabitants, and IBD patients have been attended in a monographic unit since 2002. Assistance in this area is eminently public and reflects the current situation of the disease in our area. We collected data on IBD patients in an access database prepared for that purpose from 2004 to 2008. All patients included in this register met Lennard-Jones criteria. We used the Montreal Classification for stratification of the disease and data collected included gender, date of diagnosis and symptom onset, extraintestinal manifestations, current smoking status, treatments, and surgery. Ethics approval for the study was obtained from the local committee. Statistical analysis was carried out using SPSS v. 13 (Chicago, IL). A chi-square test, Fisher's exact test for small samples, and the Mann–Whitney U-test for heterogeneous samples were used for analysis. A total of 200 patients with UC were included. We observed, as in the Portuguese group, a predominance of females: 57.7% overall. In the majority of UC studies no gender differences were reported, although the female:male ratio in the European Collaborative Study on Inflammatory Bowel Disease2 (EC-IBD) was the inverse. Later, Arin et al,3 also in Spain, found a male preponderance. The predominance of women in our population, as in the north of Portugal, may be due to several factors: hormonal, environmental, or even due to changes in the current pattern of smoking in women. In our cohort 33% of patients were nonsmokers, with a predominance of women (41.8% versus 21.3%, P = 0.006), and 42.1% were exsmokers. The median age at diagnosis was consistent with most studies, 39.91 ± 16.54 years, while the median of disease since diagnosis was 8.2 ± 7.6 years. The peak of incidence was in the age group between 35 and 45 years old. A second peak at older ages has not been uniformly described; it was apparent in our population in males, but not in women, where the incidence decreases gradually. With regard to classification of disease extent, left-sided colitis (E2 in Montreal Classification) was the most frequent: 86 patients (43%), 60 (29.5%) had proctitis (E1), and 54 (27.5%) extensive colitis (E3). Proctitis was significantly more frequent in women (35.3% versus 21.1%, P = 0.04) and extensive colitis in men (35.1% versus 22.4%, P = 0.03). We have not found this relationship previously described, and it can justify the higher percentage of women in our population: cases of proctitis in men might remain undiagnosed while women more frequently consult despite mild disease. Regarding management of disease, it has become increasingly complicated because of the new therapies. Our data show that a large proportion of patients are successfully managed with mesalamine, which has a high safety profile: 68.8% of our patients were taking oral 5-aminosalicylates (ASA) for maintenance and up to 26% used topical 5-ASA. These figures are higher than those described in previous studies: Farmer et al4 referred only 37% of patients under maintenance therapy, while studies closest to us1, 5 reflect figures more similar to ours (53%–65%). A great emphasis is now being placed on a more intensive management in patients with Crohn's disease (CD). Immunomodulators (IM) have traditionally been less used in UC than in CD, but a more intense treatment may also improve the evolution of this disease, and therefore, diminish the need for colectomy. In the study by Barreiro et al, 15% of patients were taking immunosuppressant drugs and 3% received biological therapies. Our data support this observation: 16% were taking IM, mostly azathioprine, and 4% of patients were taking biologic agents. Older studies reported lower percentages (0%–6%),6 but more recent rates range between 0 and 28%.7 In the other hand, surgery rates in most studies fluctuate between 9% and 39%. Recently, in the IBSEN study,8 the cumulative colectomy rate after 10 years of disease was 9.8%. In our population only 4% of patients had undergone colectomy. Maintenance therapy with good compliance with 5-ASA and early initiation of immunosuppressives could allow a more benign course of disease, and hence, a lower rate of surgery than is mostly reported. The question is to identify those risk factors associated with a worse prognosis that might indicate the need for a more intense therapy. Extensive location of the disease was associated with oral mesalamine (P = 0.006), immunosuppressors (P = 0.03), steroids (P = 0.02), and surgery (P = 0.02) in our cohort. Also, it has been associated with a poor prognosis previously and by Barreiro et al. However, although they found a statistical association between biological therapies and extensive colitis, we could not prove it. We did not find a statistical association between age at diagnosis, sex, or smoking status and colectomy or immunosuppressive treatment; however nonsmoking patients need IM and surgery more frequently (differences not statistically significant). We know there is an important limitation in our study: it is a monocenter study in a small area in Madrid, but the results are mostly concordant with that of Barreiro et al: most patients are correctly managed with 5 ASA, but an increasing percentage of patients need either immunosuppressants or biological therapies. These therapies have become the first-line treatment for a nonnegligible percentage of patients and proper use may allow better outcomes for these patients. Extensive colitis is a risk factor for more severe disease.

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