Although systemic
steroids are highly efficacious in
ulcerative colitis (UC), failure to respond to
steroids still poses an important challenge to the surgeon and physician alike. Even if the life time risk of a fulminant UC flare is only 20%, this condition is potentially life threatening and should be managed in hospital. If patients fail 3 to 5 d of intravenous
corticosteroids and optimal supportive care, they should be considered for any of three options: intravenous
cyclosporine (2 mg/kg for 7 d, and serum level controlled),
infliximab (5 mg/kg IV, 0-2-6 wk) or total
colectomy. The choice between these three options is a medical-surgical decision based on clinical signs, radiological and endoscopic findings and blood analysis (CRP,
serum albumin). Between 65 and 85% of patients will initially respond to
cyclosporine and avoid
colectomy on the short term. Over 5 years only 50% of initial responders avoid
colectomy and outcomes are better in patients naive to
azathioprine (bridging strategy). The data on
infliximab as a medical rescue in fulminant
colitis are more limited although the efficacy of this anti
tumor necrosis factor (TNF)
monoclonal antibody has been demonstrated in a controlled trial. Controlled data on the comparative efficacy of
cyclosporine and
infliximab are not available at this moment. Both drugs are
immunosuppressants and are used in combination with
steroids and
azathioprine, which infers a risk of serious, even fatal,
opportunistic infections. Therefore, patients not responding to these agents within 5-7 d should be considered for
colectomy and responders should be closely monitored for
infections.