Background and Aim: Corticosteroid therapy fails in about 40% of patients with acute severe ulcerative colitis (ASUC). It is important to develop criteria that can predict steroid failure earlier. Our aim was to identify variables at admission (clinical, biochemical, and endoscopic) and develop a novel Day 1 score for predicting steroid failure.

Methods: All admissions for ASUC (fulfilling Truelove and Witts criteria) between 2015 and 31 July 2020 at Gold Coast University Hospital and from 2018 to 31 July 2020 at Logan Hospital were retrospectively analyzed. Steroid failure was defined as need for rescue therapy (medical or surgical). To test for independent predictive factors, a logistic regression model was constructed with the requirement for rescue therapy as the dependent variable.

Results: A total of 149 patients with 188 episodes of ASUC were analyzed. Of these, 43 episodes (22.9%) were in patients using biological therapy at presentation (26 anti-tumor necrosis factor antagonists, 17 vedolizumab), and 73 episodes (38.8%) were in patients using oral corticosteroids at admission. There were 85 episodes (45.2%) that required rescue therapy (medical rescue in 80 episodes [15 cyclosporine, 65 infliximab] and direct colectomy in five). Seventeen episodes (9%) had same-admission colectomy. On multivariable analysis, oral steroid use at admission (Coef, 0.32; 0.17–0.47; P < 0.001), admission serum albumin level (Coef, −0.013; −0.02 to 0.007; P < 0.001), and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) (Coef, 0.12; 0.07–0.16; P < 0.001) were predictors of steroid failure. Fecal calprotectin level was not predictive of need for rescue therapy (odds ratio [OR], 1; P = 0.803). A novel score was developed (ASUC score) allocating 1 point to each variable (albumin ≤30 g/L, steroid use at admission, and UCEIS ≥7). Of 39 patients with a score ≥2, intravenous corticosteroid therapy failed in 36 (92.3%) (sensitivity, 47.7%; specificity, 96.7%; positive predictive value [PPV], 92.3%; negative predictive value [NPV], 68.2%; accuracy, 74%). Steroid therapy failed in 40 of 126 patients (32.6%) with a score <2. Twelve of 39 patients (30.8%) with an ASUC score ≥2 underwent colectomy during the same admission (sensitivity, 80%; specificity, 82%; accuracy, 82.5%; NPV, 97.8%; PPV, 30.8%). The score was accurate in identifying steroid failure (OR, 5.25; 95% CI, 3.05–9.04; P < 0.001; area under the receiver operating characteristic curve [AUROC], 0.7756) and the need for colectomy during the same admission (OR, 4.01; 95% CI, 2.18–7.38; P < 0.001; AUROC, 0.8293) (Fig. 1).

Conclusion: Intravenous corticosteroid therapy fails in 92% of patients with an ASUC score ≥2 at admission (serum Albumin ≤30 g/L, Steroid use, UCEIS ≥7), and the risk of colectomy in this group is 12 times higher compared with the whole cohort. This group may benefit from upfront second-line therapy.