Review Article

The Practical Management of Acute Severe Ulcerative Colitis

D. Seah; P. De Cruz


Aliment Pharmacol Ther. 2016;43(4):482-513. 

In This Article

Conclusions and Optimal Management Strategy

The availability of salvage therapies has changed dramatically the outlook for patients with ASUC who may previously have been destined to undergo colectomy. On the basis of the available evidence, we have proposed a strategy for the optimal management of steroid-refractory ASUC (Figure 2). The general approach advocated by current guidelines and literature comprises intensive medical therapy and close monitoring, with early surgical intervention in cases of inadequate response.

Figure 2.

Algorithm outlining optimal management strategy for acute severe ulcerative colitis. AXR, abdominal X-ray; CRP, C-reactive protein; CMV, cytomegalovirus; ELISA, enzyme-linked immunosorbent assay; ESR, erythrocyte sedimentation rate; GDH, glutamate dehydrogenase; IFX, infliximab; IV, intravenous; MRI, magnetic resonance imaging; MTX, methotrexate; PCR, polymerase chain reaction; s/c, subcutaneous; TED, thromboembolic deterrent; UCEIS, ulcerative colitis endoscopic index of severity; VTE, venous thromboembolism.

Methods for assessing responsiveness to salvage therapy are not yet clearly defined. Management decisions must account for clinical severity, with temperature and heart rate elevation as poor prognostic markers. Endoscopic evaluation for mucosal healing is valuable in predicting responsiveness to rescue therapy. Indirect markers of luminal disease activity include CRP, platelets, white cell count and haemoglobin. Therapeutic drug monitoring for infliximab appears to be predictive of outcomes in ASUC; however, further studies are needed to confirm its utility. Risk stratification based on previous response to thiopurines has been shown to be useful in determining choice of both salvage and maintenance therapies.

Close monitoring following administration of salvage therapy is necessary. The ability to predict clinical outcomes from salvage therapy is currently limited and relies on clinical gestalt to draw together several clinical parameters in order to make an informed management decision. There are substantive data demonstrating the efficacy of infliximab and ciclosporin as salvage therapy agents; however, the frequency of the dosing schedule, optimal dosing, duration of therapy and long-term outcomes of these therapies require further evaluation – especially with regard to accelerated and/or intensive dosing regimens. Irrespective of the medical treatment options available, proctocolectomy may be the best available management for some patients and should not be deferred unnecessarily. Further investigation into predictors of response to salvage therapy is therefore required to expedite surgical treatment among those who are unlikely to respond and facilitate refinement of the current management strategy.