Intravenous
steroids are considered the mainstay of treatment in patients with severe
ulcerative colitis. Several randomized controlled trials have been designed to evaluate drugs that, as an adjunct to intravenous
steroids, could obtain a clinical response and avoid
colectomy in patients who do not respond to
corticosteroids. For
steroid refractory patients,
cyclosporine and
infliximab seem to be an effective alternative to
colectomy in the short term, but more data are needed to evaluate if they can prevent
colectomy also in the long term. Although there is no evidence from the published trials that
antibiotics as adjunctive
therapy may have an additional benefit, therapeutic protocols for severe
ulcerative colitis generally include
antibiotics for patients with signs of toxicity, or with worsening of symptoms despite the medical treatment. No additional benefit over
steroids has been shown from bowel rest. Moreover, as bowel rest deprives the colonic enterocytes of the
short-chain fatty acids vital to their metabolism and repair, it may even be harmful. Conflicting results have been published on
heparin as primary treatment of severe
ulcerative colitis; at the present time there is no evidence supporting its use. Although "
steroid-free" clinical remission is, at this time, the most important end point of clinical studies in
inflammatory bowel disease, only few data are available in
steroid dependent
colitis patients.
Azathioprine seems to be effective in inducing
steroid-free remission.