Intest Res.  2018 Jul;16(3):484-488. 10.5217/ir.2018.16.3.484.

Successful remission of ulcerative colitis flare-up during pregnancy with adsorptive granulomonocytapheresis plus tacrolimus

• Shibuya T
• Haga K
• Kamei M
• Okahara K
• Ito S
• Takahashi
• Nomura O
• Murakami T
• Makino M
• Kodani T
• Ishikawa D
• Sakamoto N
• Osada T
• Ogihara T
• Watanabe S
• Nagahara A

• KMID: 2417661
• DOI: http://doi.org/10.5217/ir.2018.16.3.484

Abstract

Ulcerative colitis (UC) is 1 of the 2 major phenotypes of chronic inflammatory bowel disease (IBD), which afflicts millions of individuals throughout the world with debilitating symptoms that impair function and quality of life. Further, IBD often affects women during childbearing age. Indeed, UC activity frequently increases during pregnancy, and the medications used to induce remission may adversely affect the health of the mother and the unborn child. We report successful induction of a remission in a UC case who experienced a flare-up in the first trimester of pregnancy. Upon relapse, she was treated with steroids and adsorptive granulomonocytapheresis (GMA) with the Adacolumn plus tacrolimus. This combination therapy induced a stable remission that was maintained during her entire pregnancy. She gave birth to a healthy child at 36 weeks of pregnancy with no maternal or fetal complications. Our experience indicates that GMA, as a non-drug therapeutic intervention with a favorable safety profile, plus tacrolimus might be a relevant treatment option for patients with active IBD during pregnancy. A future study of a large cohort of pregnant patients should strengthen our findings.

Keyword

Colitis, ulcerative; Pregnancy; Tacrolimus; Granulomonocytapheresis

MeSH Terms

Child
Cohort Studies
Colitis, Ulcerative*
Female
Humans
Inflammatory Bowel Diseases
Mothers
Parturition
Phenotype
Pregnancy Trimester, First
Pregnancy*
Quality of Life
Recurrence
Steroids
Tacrolimus*
Ulcer*
Steroids
Tacrolimus

Figure

• 

  Fig. 1 Clinical course of a pregnant patient who achieved clinical remission during treatment with adsorptive granulomonocytapheresis (GMA) with the Adacolumn in combination with tacrolimus. The bold down arrows indicate GMA. CAI, clinical activity index; PSL, prednisolone; Cr, creatinine.

Reference

1. Barbarino JM, Staatz CE, Venkataramanan R, Klein TE, Altman RB. PharmGKB summary: cyclosporine and tacrolimus pathways. Pharmacogenet Genomics. 2013; 23:563–585. PMID: 23922006.

2. Harbord M, Eliakim R, Bettenworth D, et al. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 2: current management. J Crohns Colitis. 2017; 11:769–784. PMID: 28513805.

3. Mahadevan U, Sandborn WJ, Li DK, Hakimian S, Kane S, Corley DA. Pregnancy outcomes in women with inflammatory bowel disease: a large community-based study from Northern California. Gastroenterology. 2007; 133:1106–1112. PMID: 17764676.

4. Pedersen N, Bortoli A, Duricova D, et al. The course of inflammatory bowel disease during pregnancy and postpartum: a prospective European ECCO-EpiCom Study of 209 pregnant women. Aliment Pharmacol Ther. 2013; 38:501–512. PMID: 23855425.

5. Hibi T, Sameshima Y, Sekiguchi Y, et al. Treating ulcerative colitis by Adacolumn therapeutic leucocytapheresis: clinical efficacy and safety based on surveillance of 656 patients in 53 centres in Japan. Dig Liver Dis. 2009; 41:570–577. PMID: 19211314.

6. Saniabadi AR, Hanai H, Suzuki Y, et al. Adacolumn for selective leukocytapheresis as a non-pharmacological treatment for patients with disorders of the immune system: an adjunct or an alternative to drug therapy? J Clin Apher. 2005; 20:171–184. PMID: 15892107.

7. Takahashi H, Sugawara K, Sugimura M, et al. Flare up of ulcerative colitis during pregnancy treated by adsorptive granulocyte and monocyte apheresis: therapeutic outcomes in three pregnant patients. Arch Gynecol Obstet. 2013; 288:341–347. PMID: 23404436.

8. EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol Dial Transplant. 2002; 17(Suppl 4):50–55.

9. Korelitz BI. Inflammatory bowel disease and pregnancy. Gastroenterol Clin North Am. 1998; 27:213–224. PMID: 9546091.

10. Hviid A, Mølgaard-Nielsen D. Corticosteroid use during pregnancy and risk of orofacial clefts. CMAJ. 2011; 183:796–804. PMID: 21482652.

11. Branche J, Cortot A, Bourreille A, et al. Cyclosporine treatment of steroid-refractory ulcerative colitis during pregnancy. Inflamm Bowel Dis. 2009; 15:1044–1048. PMID: 19137604.

12. Baumgart DC, Sturm A, Wiedenmann B, Dignass AU. Uneventful pregnancy and neonatal outcome with tacrolimus in refractory ulcerative colitis. Gut. 2005; 54:1822–1823.

13. Ogata H, Kato J, Hirai F, et al. Double-blind, placebo-controlled trial of oral tacrolimus (FK506) in the management of hospitalized patients with steroid-refractory ulcerative colitis. Inflamm Bowel Dis. 2012; 18:803–808. PMID: 21887732.

14. Marri SR, Ahn C, Buchman AL. Voluntary childlessness is increased in women with inflammatory bowel disease. Inflamm Bowel Dis. 2007; 13:591–599. PMID: 17206690.

15. Tavernier N, Fumery M, Peyrin-Biroulet L, Colombel JF, Gower-Rousseau C. Systematic review: fertility in non-surgically treated inflammatory bowel disease. Aliment Pharmacol Ther. 2013; 38:847–853. PMID: 24004045.

16. Pérgola PE, Kancharla A, Riley DJ. Kidney transplantation during the first trimester of pregnancy: immunosuppression with mycophenolate mofetil, tacrolimus, and prednisone. Transplantation. 2001; 71:994–997. PMID: 11349738.

17. Armenti VT, Constantinescu S, Moritz MJ, Davison JM. Pregnancy after transplantation. Transplant Rev (Orlando). 2008; 22:223–240. PMID: 18693108.

18. Khan SS, Constantinescu S, Silva P, Coscia LA, Armenti VT. Pregnancy outcomes in renal transplant recipients on Neoral vs. tacrolimus. J Am Soc Nephrol. 2006; 17:562A.

19. Kainz A, Harabacz I, Cowlrick IS, Gadgil SD, Hagiwara D. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation. 2000; 70:1718–1721. PMID: 11152103.