Management of Acute Severe Ulcerative Colitis After Failed IV Steroid Therapy
For a child with acute severe ulcerative colitis who has not responded to 5 days of IV steroids, rescue therapy with infliximab should be initiated immediately, with consideration for surgical consultation if no improvement occurs within 5-7 days of rescue therapy.
Assessment of Steroid Failure
The lack of response to IV steroids after 5 days meets established criteria for steroid-refractory disease. According to the British Society of Gastroenterology guidelines, steroid failure is defined by:
- On day 3: >8 stools per day or 3-8 stools with CRP >45 mg/L
- On day 7: >3 stools per day or visible blood
- For pediatric patients: PUCAI score >65 on day 5 1
Additional severity indicators include:
- Mucosal islands on abdominal X-ray
- Colonic dilatation
- Deep ulceration on flexible sigmoidoscopy 1
Recommended Rescue Therapy
First-line Rescue Option: Infliximab
Infliximab is recommended as the preferred rescue therapy for several reasons:
- Established efficacy in steroid-refractory ASUC in pediatric patients 1
- FDA-approved for pediatric ulcerative colitis from age 6 and above 2
- Standard dosing: 5 mg/kg IV at weeks 0,2, and 6, followed by maintenance every 8 weeks 2
- Better long-term outcomes compared to ciclosporin 1
For patients with low serum albumin or high inflammatory burden, consider an intensified dosing regimen after surgical consultation 1.
Alternative Rescue Option: Ciclosporin
Ciclosporin (2 mg/kg/day IV) can be considered as an alternative rescue therapy, particularly in:
- Infliximab-contraindicated patients
- Patients with previous infliximab exposure 1
However, ciclosporin should NOT be used in patients who have previously failed thiopurine therapy, as the colectomy rate is significantly higher (59%) in these patients 1.
Monitoring Response to Rescue Therapy
Close monitoring is essential during rescue therapy:
- Daily clinical assessment
- Regular laboratory tests (CBC, CRP, albumin)
- Surgical consultation if no improvement within 48-72 hours of rescue therapy
- Consider colectomy if no response after 5-7 days of rescue therapy 1
Surgical Considerations
Surgical consultation should be obtained early in the course of rescue therapy. Colectomy should be considered if:
- No improvement after 5-7 days of rescue therapy
- Clinical deterioration at any point
- Development of complications (toxic megacolon, severe hemorrhage, perforation) 1
Delaying surgery in non-responders is associated with increased postoperative complications 1.
Maintenance Therapy After Successful Rescue
If the patient responds to infliximab rescue therapy:
- Complete the induction regimen (doses at weeks 0,2, and 6)
- Initiate maintenance therapy with infliximab (5 mg/kg every 8 weeks)
- Consider adding a thiopurine (if thiopurine-naïve) for combination therapy 1
Common Pitfalls to Avoid
- Delaying rescue therapy decision: Assess response to IV steroids by day 3-5 and initiate rescue therapy promptly if criteria for steroid failure are met
- Prolonged rescue attempts: Limit rescue therapy to 5-7 days before considering colectomy
- Overlooking infections: Screen for C. difficile and CMV infections, which can mimic or exacerbate ASUC
- Using ciclosporin in thiopurine-experienced patients: Higher failure rates make this a poor choice 1
- Inadequate VTE prophylaxis: Ensure low-molecular-weight heparin is administered 1
Special Considerations for Pediatric Patients
- Use the Pediatric Ulcerative Colitis Activity Index (PUCAI) to assess disease severity
- PUCAI >65 on day 5 of IV steroids indicates need for rescue therapy 1
- Ensure appropriate weight-based dosing of medications
- Consider nutritional support if malnourished 1
By following this algorithm, the management of steroid-refractory acute severe ulcerative colitis in children can be optimized to improve outcomes and reduce morbidity and mortality.