Broadening perspectives in the treatment of chronic pouchitis

We present the case of a 64-year-old male diagnosed with corticosteroid-dependent ulcerative colitis in 1999, who underwent total proctocolectomy with a J-pouch in 2005. Three years later, he developed recurrent histologically confirmed pouchitis, with clinical worsening. Several therapies were tried, including Infliximab, which provided stability for six years, until the development of antibodies led to moderate pouchitis in the rectal stump. Attempts with Adalimumab, Vedolizumab, and Ustekinumab failed, leading to worsening cuffitis, pouchitis, and anastomotic stenosis. Tofacitinib was started at 10 mg/12h, leading to a >50% reduction in fecal calprotectin and a PDAI drop from 4 to 0 within four weeks. After reducing the dose to 5 mg/12h, disease control was maintained, and the patient remains asymptomatic after two years and seven months, with normal colonoscopy findings showing complete mucosal healing. Despite advances in treatment, around 15% of ulcerative colitis patients require surgery, and 30-50% of those develop acute or chronic cuffitis or pouchitis. Tofacitinib, a JAK inhibitor, is approved for ulcerative colitis but has shown inconsistent results in treating pouchitis and cuffitis. While some studies report a lack of efficacy, others show potential responses in refractory cases. More research with larger patient cohorts is needed to better understand the role of JAK inhibitors in this context.