Management of acute severe ulcerative colitis-an update for generalist and specialist clinicians.

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening medical emergency that occurs in up to 25% of patients with ulcerative colitis. Although intravenous corticosteroids remain the cornerstone of therapy, 30-40% of patients will not respond and need timely consideration of rescue therapy with (currently) either infliximab or ciclosporin or indeed colectomy, underscoring the importance of multidisciplinary care to ensure favourable outcomes for patients. We discuss the current evidence and present an approach to the management of ASUC for general and specialist clinicians caring for patients with ASUC. The information in this review is derived from data published in peer- reviewed academic journals and registered clinical trials. Management of acute severe colitis requires a multidisciplinary approach with early initiation with steroids and timely escalation of treatment to either medical rescue therapy or surgery. Balancing the risks of delayed surgery vs. optimizing medical therapy, including accelerated dosing schedules for biologics, remains ambiguous. The position on newer molecules like Janus Kinase inhibitors, such as tofacitinib, is a growing area with early real-world data showing promise for steroid refractory ASUC. Developing predictive biomarkers and clinical risk scores for personalized rescue therapy selection is an evolving area of research.

Kuriakose Kuzhiyanjal AJ ，Limdi JK 《-》

Acute Severe Ulcerative Colitis: Optimal Strategies for Drug Therapy.

Nakase H 《-》

Optimal management of acute severe ulcerative colitis.

Acute severe ulcerative colitis is a life-threatening medical emergency, which can be associated with significant morbidity and is preventable through prompt and effective management. Corticosteroids remain the cornerstone of initial therapy, although a third of patients will not respond. Further management hinges on timely decisions with use of rescue therapy with ciclosporin or infliximab, without compromising the health or safety of the patient, or timely surgery. Although such patients need specialist care, it is imperative that emergency care physicians are aware of the important principles of management of this condition to achieve successful outcomes. Risk stratification and the use of predictive models using clinical parameters have reduced the morbidity associated with this condition.We discuss current evidence and present a clinical approach to clinicians involved in the emergency care of patients with acute severe ulcerative colitis in this review.

Jain S ，Ahuja V ，Limdi JK 《-》

Randomised controlled trial. Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: Trial design and protocol (CONSTRUCT).

Seagrove AC ，Alam MF ，Alrubaiy L ，Cheung WY ，Clement C ，Cohen D ，Grey M ，Hilton M ，Hutchings H ，Morgan J ，Rapport F ，Roberts SE ，Russell D ，Russell I ，Thomas L ，Thorne K ，Watkins A ，Williams JG ... -  《BMJ Open》

Review article: the practical management of acute severe ulcerative colitis.

Acute severe ulcerative colitis (ASUC) is a life-threatening condition for which optimal management strategies remain ill-defined. To review the evidence regarding the natural history, diagnosis, monitoring and treatment of ASUC to inform an evidence-based approach to management. Relevant articles addressing the management of ASUC were identified from a search of MEDLINE, the Cochrane Library and conference proceedings. Of ASUC, 31-35% is steroid-refractory. Infliximab and ciclosporin salvage therapies have improved patient outcomes in randomised controlled trials. Short-term response rates (within 3 months) have ranged from 40% - 54% for ciclosporin and 46-83% for infliximab. Long-term clinical response rates (≥1 year) have ranged from 42%-50% for ciclosporin and 50-65% for infliximab. Short-term and long-term colectomy rates have been respectively: 26-47% and 36-58% for ciclosporin, and 0-50% and 35-50% for infliximab. Mortality rates for ciclosporin and infliximab-treated patients have been: 0-5% and 0-2%, respectively. At present, management challenges include the selection, timing and assessment of response to salvage therapy, utilisation of therapeutic drug monitoring and long-term maintenance of remission. Optimal management of acute severe ulcerative colitis should be guided by risk stratification using predictive indices of corticosteroid response. Timely commencement and assessment of response to salvage therapy is critical to reducing morbidity and mortality. Emerging pharmacokinetic models and therapeutic drug monitoring may assist clinical decision-making and facilitate a shift towards individualised acute severe ulcerative colitis therapies.

Seah D ，De Cruz P 《-》