Therapeutic options for steroid-refractory ulcerative colitis

Approximately 15% of patients with ulcerative colitis will experience a severe episode requiring hospitalization. Although intravenous steroids are the current first-line therapy for these patients, about 30% of patients do not respond to steroids, and require either an alternative anti-inflammatory agent or surgery. Cyclosporine has proven its efficacy in a number of controlled trials in this setting, and is characterized by high early response rates. Patients that respond to cyclosporine and avoid colectomy are more likely to retain their colon if they bridge to immuno-modulators in the medium-term. Infliximab has also demonstrated efficacy in reducing early colectomy rates, and longer term data are awaited. Other agents such as visilizumab, tacrolimus, basiliximab, and leukocytaphereis have been studied in small or open-labeled trials, and may be alternative options. Key issues remain as to what should be first and second line therapies, when surgery should be undertaken, and the risk of overlapping immuno-suppressants in patients with severe colitis.