Purpose of review: Steroid-refractory acute severe colitis (ASC) poses a significant clinical challenge to both physicians and surgeons alike. This review highlights advances in management of these patients and the role of cyclosporine compared to infliximab.
Recent findings: ASC affects 25% of patients with ulcerative colitis and is associated with measurable morbidity and mortality. Simple clinical and laboratory measures predict steroid refractoriness (such as stool frequency 3-8/day and C-reactive protein > 45 mg/l on day 3) and salvage therapy is appropriate at this stage. Preliminary data from randomized controlled trials suggest that early (7 and 98 day) response to cyclosporine and infliximab are comparable. Serum trough infliximab concentrations may correlate with outcome. Sequential therapy cannot usually be recommended due to limited response (70% colectomy at 3 years) and high rate of serious adverse events.
Summary: Optimal salvage therapy will depend on detailed results of randomized controlled trials. Meanwhile, patients with ASC should receive either cyclosporine or infliximab before surgery as long as there is specialist expertise that allows early decision-making.