Lessons from extended induction and practical evidence for improving tofacitinib therapy in ulcerative colitis

With the introduction of Janus kinase inhibitors like tofacitinib, the treatment landscape for ulcerative colitis (UC) is changing quickly. Response heterogeneity is still a significant clinical challenge in spite of its quick onset and oral convenience. Extending tofacitinib induction beyond the standard eight weeks can produce significant benefits in a subset of patients without sacrificing safety, according to evidence from pivotal trials and real-world studies. We review recent real-world evidence, highlight lessons learnt from extended induction therapy, and present a practical framework to help guide tailored treatment decisions in this editorial. After 16 weeks of prolonged induction, more than half of patients with moderate-to-severe UC experienced remission, with durable persistence and favorable safety, according to a multicenter 52-week real-world study published in this issue of the World Journal of Gastroenterology. Crucially, outcomes and maintenance dosing were impacted by modifiable factors like smoking and biologic exposure. Mechanistic findings support a response-guided rather than fixed-duration induction paradigm by indicating that immune kinetics, mucosal healing rates, and previous biologic exposure may account for delayed responses. An effective, patient-centered strategy that could maximize tofacitinib's therapeutic potential and assist in guiding refractory UC patients towards long-term remission is extended induction.