Review article: the optimal medical management of acute severe ulcerative colitis

Management of acute severe ulcerative colitis (UC) is a clinical challenge, with a mortality rate of approximately 1-2%. The traditional management with intravenous corticosteroids has been modified by introduction of ciclosporin and more recently, infliximab.

To provide a detailed and comprehensive review of the medical management of acute severe UC.

PubMed and recent conference abstracts were searched for articles relating to treatment of acute severe UC.

Two-thirds of patients respond to intravenous steroids in the short term. In those who fail steroids, low-dose intravenous ciclosporin at 2 mg/kg/day is effective. Approximately 75% and 50% of patients treated with ciclosporin avoid colectomy in the short and long-terms, respectively. Long-term outcome of ciclosporin therapy is improved by introduction of azathioprine on discharge from hospital, together with oral ciclosporin as a bridging therapy. Controlled data show that infliximab is effective as rescue therapy for acute severe UC and the effect appears to be durable, although longer-term follow-up data are needed.

Both ciclosporin and infliximab have demonstrated efficacy as rescue medical therapies in patients with acute severe UC, but surgery needs to be considered if there is failure to improve or clinical deterioration.