Management of acute severe ulcerative colitis

Area of Science:

• Gastroenterology
• Immunology
• Colorectal Surgery

Background:

• Acute severe ulcerative colitis (ASUC) is a life-threatening condition requiring prompt intervention.
• Intravenous corticosteroids are the standard first-line treatment for ASUC.
• Failure to respond to corticosteroids necessitates rescue medical therapy or colectomy.

Purpose of the Study:

• To review current evidence on rescue medical therapies for ASUC.
• To compare the roles of intravenous cyclosporine and infliximab as rescue treatments.
• To guide clinical decision-making in managing refractory ASUC.

Main Methods:

• Review of controlled evidence supporting cyclosporine and infliximab in ASUC.
• Analysis of treatment profiles, including safety, efficacy, and patient-specific factors.
• Discussion of the impact of rescue therapies on subsequent colectomy decisions.

Main Results:

• Both cyclosporine and infliximab are effective rescue therapies for ASUC unresponsive to steroids.
• No direct comparative trials exist, making definitive guidance on agent choice challenging.
• Cyclosporine offers rapid onset for imminent colectomy risk; infliximab has a better short-term safety profile and maintenance potential, especially in immunosuppressive-exposed patients.

Conclusions:

• Rescue therapy with cyclosporine or infliximab should not delay colectomy in non-responders.
• The choice between cyclosporine and infliximab depends on clinical context, including prior immunosuppressive exposure and urgency for colectomy.
• While rescue therapies may postpone colectomy, elective surgery at a later stage might improve outcomes, though peri-operative risks associated with these agents are still debated.