Optimizing steroid treatment for UC patients with CMV colitis: a multicenter real-world study

Ulcerative colitis (UC) patients with concomitant cytomegalovirus (CMV) colitis face higher disease activity and poorer prognosis. While antiviral therapy improves outcomes, optimal immunosuppressive management during treatment remains controversial, particularly regarding steroid use.

In this two-center retrospective study, hospitalized patients with moderate-to-severe UC with concomitant CMV colitis from January, 2013 to February, 2024 were stratified into stratified into three groups by steroid strategy post-CMV diagnosis: intensified treatment, steroid tapering, and steroid non-initiation. Primary outcome was colectomy on Week 26 since the diagnosis of CMV colitis. Secondary outcome included clinical response and remission on the 7th and 14th day, and colectomy on Week 52. Multivariate logistic regression adjusted for confounders was used for analysis.

Baseline steroid cumulative dose differed significantly across groups: highest in the tapering group (2.2 ± 2.0 g), intermediate in the intensified group (0.6 ± 1.2 g), and absent in the non-initiation group (0 g, all P < 0.001). After adjustment, the intensified group had a significantly lower Week 26 colectomy risk vs. non-initiation (adjusted OR = 0.1, 95%CI = 0.02-0.9, P = 0.035) and higher Day 7 clinical response (adjusted OR = 4.5, 95%CI = 1.1-18.9, P = 0.041); Day 7 remission trended higher but was not significant (adjusted OR = 14.1, 95%CI = 0.9-213.9, P = 0.057). At Week 52, the intensified group still had lower colectomy risk vs. non-initiation (adjusted OR = 0.1, 95%CI = 0.02-0.9, P = 0.040). No significant differences in short- or long-term outcomes were observed between the intensified and tapering groups.

Steroid strategies for UC with CMV colitis require context-specific adjustments based on baseline steroid exposure. Intensified treatment outperforms steroid non-initiation in improving short-term response and reducing long-term colectomy risk, while showing no inferiority to tapering. Individualized therapy balancing immediate and long-term outcomes is critical.