What's the next step in managing a 40-year-old woman with ulcerative colitis, presenting with bloody diarrhea and abdominal pain, who hasn't responded to intravenous (IV) steroids and has elevated leukocyte count and mild hyperlactatemia?

From the Guidelines

The next step in managing this patient is to initiate rescue therapy with either infliximab or cyclosporine while consulting colorectal surgery for possible colectomy. The patient has steroid-refractory acute severe ulcerative colitis, as evidenced by ongoing bloody diarrhea, abdominal pain, elevated white blood cell count, and hyperlactatemia despite IV steroid treatment 1. According to the British Society of Gastroenterology consensus guidelines, patients with more than 8 bowel movements per day and elevated CRP levels should be considered for surgical review for colectomy 1.

Key Considerations

• The patient's symptoms, including 8 bowel movements in 24 hours, abdominal pain, and decreased appetite, indicate a lack of response to IV steroid treatment.
• The elevated leukocyte count and mild hyperlactatemia suggest ongoing inflammation and potential complications.
• Stool testing for C. difficile and CMV colitis should be performed to rule out other causes of symptoms, although C. difficile toxin is already negative in this case.
• Close monitoring of vital signs, electrolytes, and inflammatory markers is essential, with daily abdominal examinations to detect signs of toxic megacolon or perforation.

Treatment Options

• Infliximab can be administered at 5-10 mg/kg intravenously, with follow-up doses at weeks 2 and 6.
• Cyclosporine can be given as a continuous infusion at 2 mg/kg/day with monitoring of drug levels.
• Surgical consultation should be obtained early, as approximately 30% of patients with steroid-refractory colitis ultimately require colectomy 1.

Monitoring and Follow-up

• If no improvement occurs within 3-7 days of rescue therapy, urgent colectomy is recommended as delayed surgery in fulminant colitis increases mortality risk 1.
• Daily senior gastroenterology review and surgical review if continued systemic toxicity, severe abdominal pain, or suspicion of toxic megacolon or perforation are essential 1.

From the FDA Drug Label

In addition, a greater proportion of patients in infliximab groups demonstrated sustained response and sustained remission than in the placebo groups Of patients on corticosteroids at baseline, greater proportions of patients in the infliximab treatment groups were in clinical remission and able to discontinue corticosteroids at Week 30 Clinical response at Week 8 was defined as a decrease from baseline in the Mayo score by ≥ 30% and ≥ 3 points, including a decrease in the rectal bleeding subscore by ≥ 1 points or achievement of a rectal bleeding subscore of 0 or 1.

The next step in managing this patient with ulcerative colitis who hasn't responded to IV steroids is to consider initiating infliximab therapy 2, as the patient has had an inadequate response to conventional therapy. The patient's symptoms, including 8 bowel movements in 24 hours, abdominal pain, and decreased appetite, along with elevated leukocyte count and mild hyperlactatemia, suggest a need for alternative treatment. Infliximab has been shown to be effective in inducing and maintaining clinical remission in patients with moderately to severely active ulcerative colitis.

Key considerations for the next step include:

• The patient's lack of response to IV steroids
• The presence of elevated leukocyte count and mild hyperlactatemia
• The potential benefits of infliximab therapy in inducing and maintaining clinical remission
• The need for close monitoring of the patient's response to therapy and adjustment of the treatment plan as needed.

From the Research

Patient Status

The patient is a 40-year-old woman with a history of ulcerative colitis, presenting with bloody diarrhea and abdominal pain. She has been treated with IV fluids and IV steroids but has not responded adequately, as evidenced by 8 bowel movements in 24 hours, abdominal pain, decreased appetite, lactate level of 1.8 mmol/L, and a high leukocyte count of 13,000.

Treatment Considerations

Given the patient's lack of response to IV steroids, the next step in management should consider rescue therapies. According to 3, infliximab and cyclosporine are equally effective rescue agents for acute severe ulcerative colitis that does not respond to steroids. The choice between these two may depend on factors such as previous exposure to these medications, potential side effects, and the patient's specific condition.

Rescue Therapy Options

• Infliximab: This is a viable option for patients who have not responded to steroid treatment. Studies such as 4 and 5 demonstrate the effectiveness of infliximab in improving symptoms and potentially avoiding colectomy in patients with refractory ulcerative colitis.
• Cyclosporine: Also an effective rescue therapy, as noted in 3 and 6. The decision to use cyclosporine or infliximab may depend on the clinical context and patient factors.

Long-Term Outcomes

The long-term outcomes of cyclosporine and infliximab in patients with steroid-refractory acute severe ulcerative colitis are comparable, as shown in 6. This suggests that either medication could be a reasonable choice for rescue therapy, with the decision guided by individual patient factors and clinical judgment.

Next Steps

Considering the patient's condition and the lack of response to initial steroid treatment, initiating a rescue therapy such as infliximab or cyclosporine should be considered. The choice between these therapies should be based on a comprehensive evaluation of the patient's history, current condition, and potential risks and benefits associated with each medication, as informed by studies such as 3, 4, 5, and 6.