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

Sequential Therapy

Second-line rescue therapy, following nonresponse to initial infliximab or ciclosporin remains controversial. While so-called sequential therapy for refractory flares appears to halt progression to colectomy, such intensive immunosuppression raises safety concerns.[107–109]

A retrospective analysis compared outcomes in patients given infliximab therapy following ciclosporin failure, to those given ciclosporin after infliximab nonresponse.[109] A total of 86 patients received sequential therapy, 65 (76%) were given ciclosporin then infliximab and 21 (24%) were given infliximab then ciclosporin. At 3- and 6-month follow-up, the colectomy-free survival rates of ciclosporin nonresponders, who received infliximab were 60% and 55% respectively. Colectomy-free survival in infliximab nonresponders who received ciclosporin was 66% and 45% at 3 and 6 months respectively. Nineteen patients (22%) suffered from adverse events following second-line salvage therapy, including one death (pulmonary embolus). Chaparro et al. likewise noted that the rate of colectomy-free survival was 30% following infliximab treatment after ciclosporin nonresponse, but the rate of adverse events was 23% (11/47 patients), once again including one death, due to nosocomial pneumonia.[108]

Profound immunosuppression appears to be the limiting factor in sequential therapy and any therapeutic response must be carefully weighed against the risk of potentially fatal infectious complications.