P0800 - Oral Vancomycin Therapy for the Treatment of PSC-Related IBD Colitis and Pouchitis

Gizem Kaya, MD¹, Joseph Sleiman, MD², Amir Ali Ghaffari, MD, PhD², Jeffrey M. Dueker, MD, MPH^2
1UPMC, Harrisburg, PA; ²UPMC, Pittsburgh, PA

Introduction: Previous case series have reported that oral vancomycin therapy is effective for patients with concurrent primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD). It is proposed that PSC-IBD is driven by microbiome dysregulation, distinct from healthy controls and from IBD alone. Vancomycin is also potent inhibitor of secondary bile acid production in PSC-IBD patients and may increase systemic CD8+ dendritic cells. We report four cases of PSC-IBD colitis and pouchitis which responded to oral vancomycin therapy.

Case Description/Methods: We queried our IBD patient registry for patients who have a diagnosis of PSC, IBD, and were also prescribed vancomycin, without a diagnosis of C diff. Of 29 patients, 4 were eligible for inclusion.

A young woman had persistent Mayo 2 colitis despite treatment with mesalamine (5ASA), vedolizumab (VDZ), then infliximab (IFX), with fecal calprotectin (FCP) >1000 mcg/g. She was transitioned to vancomycin 250 mg BID, with repeat colonoscopy 8 months revealing Mayo 0 colitis.

Next, a young man with liver transplantation x 2 had persistent colitis despite use of tacrolimus, 5ASA, and vancomycin 250 mg BID. Colonoscopy showed Mayo 2 colitis, so vancomycin was increased to 500 mg BID, and a follow up FCP was only 28 mcg/g, compared to prior of 2000 mcg/g.

A young man underwent a total abdominal colectomy with ileorectal anastomosis for a cecal colon cancer, pT1 N0. Post-operatively, on no medications, he had recurrent Mayo 2 proctitis and distal ileitis. After 5ASA suppositories were not effective, he was started on vancomycin 250 mg twice a day. A follow up flexible sigmoidoscopy 6 months later showed Mayo 0 colitis.

A young woman with a prior total proctocolectomy and ileal pouch-anal anastomosis struggled with ongoing chronic antibiotic refractory pouchitis despite VDZ every 4 weeks. She was started on vancomycin 250 mg twice a day, and repeat pouchoscopy should near-resolution of pouchitis.

Discussion: These cases add to the literature that vancomycin is effective for PSC-IBD, particularly in patients whom had non-response to traditional therapies. Vancomycin can also be used effectively prior to escalation to biologics. While the long-term safety of this therapy is less known, the risk of vancomycin-resistant enterococcus (VRE) is low. Vancomycin therapy may be appropriately positioned after 5ASAs but before escalation to biologic therapy, due to relative efficacy, immunosuppression sparing, and cost considerations.



Disclosures:


Gizem Kaya, MD¹, Joseph Sleiman, MD², Amir Ali Ghaffari, MD, PhD², Jeffrey M. Dueker, MD, MPH². P0800 - Oral Vancomycin Therapy for the Treatment of PSC-Related IBD Colitis and Pouchitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.