Management of Severe Ulcerative Colitis Not Responding to Initial Therapy
Initiate infliximab as rescue therapy is the best next step for this patient with severe ulcerative colitis who is not responding to intravenous corticosteroids after 5 days.
Assessment of Current Status
This 40-year-old woman presents with clear signs of acute severe ulcerative colitis (ASUC) that is not responding to initial therapy:
- 8 bowel movements in the past 24 hours
- Persistent abdominal pain despite 5 days of IV methylprednisolone
- Decreased appetite
- Tachycardia (104 bpm)
- Hypotension (105/60 mmHg)
- Laboratory evidence of anemia (Hgb 8.1 g/dL) and leukocytosis (13,000/μL)
- Sigmoidoscopy findings consistent with ulcerative colitis
Decision Algorithm for ASUC Management
Step 1: Identify Non-Response to Initial Therapy
The British Society of Gastroenterology (BSG) guidelines clearly state that patients with ASUC not responding to at least 3 days of IV corticosteroids should be treated with rescue therapy 1. This patient has received 5 days of IV methylprednisolone with inadequate response.
Step 2: Apply Predictive Criteria
Several predictive indices help identify patients who will fail corticosteroid therapy:
- Oxford criteria: >8 stools per day or 3-8 stools with CRP >45 mg/L on day 3 corresponds to 85% rate of colectomy 1
- Swedish index (fulminant colitis index): stool frequency/day + 0.14 × CRP (mg/L) >8 has a 72% positive predictive value for colectomy 1
Our patient has 8 bowel movements per day after 5 days of therapy, meeting criteria for rescue therapy.
Step 3: Select Appropriate Rescue Therapy
The two main rescue therapy options are:
- Infliximab
- Ciclosporin
Infliximab is preferred in this case because:
- It has demonstrated efficacy in severe refractory UC 1
- The BSG consensus guidelines specifically recommend infliximab or ciclosporin as rescue therapy options 1
- Ciclosporin should not be used in patients with previous thiopurine failure 1, though this patient's prior medication history is not specified
Evidence Supporting Infliximab Use
Infliximab has been shown to significantly reduce short-term colectomy rates compared to placebo in severe refractory UC 1. The European Crohn's and Colitis Organisation guidelines note that infliximab is effective in ASUC, with studies showing two-thirds of patients avoiding colectomy in the short term 1.
The recommended dosing regimen for infliximab in ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks 2.
Why Other Options Are Less Appropriate
Azathioprine (Option A): Not appropriate for acute severe disease as it has a slow onset of action (3-6 months) and would not address the immediate need for disease control.
Broad-spectrum antibiotics (Option B): Not routinely recommended in ASUC unless there is suspected infection. The patient's C. difficile test was negative, and there are no other signs of infection requiring antibiotics 1.
Colectomy (Option D): While surgery is an important option for ASUC, it is typically reserved for patients who have failed rescue therapy with infliximab or ciclosporin, or those with complications such as toxic megacolon, perforation, or severe hemorrhage 1. This patient should first be given a trial of rescue medical therapy before proceeding to surgery.
Important Considerations and Monitoring
- Close monitoring is essential during rescue therapy
- If no improvement occurs within 7 days of rescue therapy, colectomy should be considered 1
- Early surgical consultation is recommended to prepare for possible colectomy if medical therapy fails 1
- Thromboprophylaxis should be continued due to increased risk of thromboembolism in active IBD 1
Conclusion
Based on the most recent guidelines and evidence, initiating infliximab rescue therapy is the most appropriate next step for this patient with severe ulcerative colitis who has failed to respond adequately to 5 days of IV corticosteroids.