Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-Princesa], Universidad Autónoma de Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain.
Gastroenterology Department, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Sanitaria Valdecilla, Santander, Spain.
J Crohns Colitis. 2023 Jun 16;17(6):972-994. doi: 10.1093/ecco-jcc/jjad004.
One-third of patients with acute severe ulcerative colitis [ASUC] are steroid-refractory. We aimed to review the different options for the management of steroid-refractory ASUC, including not only the standard treatment [cyclosporine and infliximab], but also most recently developed agents [such as vedolizumab, ustekinumab, and tofacitinib].
We performed a bibliographical search to identify studies focusing on the treatment of steroid-refractory ASUC.
Cyclosporine and infliximab currently represent the mainstays of salvage therapy and they are generally considered comparable. However, long-term persistence is higher in infliximab therapy, and many clinicians prefer to use infliximab given its ease of use. However, cost of cyclosporine is lower. Sequential rescue therapy after cyclosporine or infliximab failure [with infliximab and cyclosporine, respectively] could be considered in referral centres for highly selected cases. Tofacitinib, due to its rapid effect, represents an attractive rescue option mainly in biologic-experienced patients. The good safety profile of vedolizumab and ustekinumab makes them ideal candidates for use as maintenance therapy in combination with cyclosporine as induction therapy, especially for patients previously exposed to anti-TNFs or thiopurines.
Although cyclosporine and infliximab still represent the mainstays of salvage therapy for steroid-refractory ASUC, new therapeutic agents may also play a role. Tofacitinib, due to its rapid effect, is an attractive therapeutic rescue option. Vedolizumab and ustekinumab, as maintenance therapy in combination with the fast-acting cyclosporine as induction therapy, may represent a promising bridging strategy, especially in patients with previous failure to thiopurines and/or anti-TNF agents.
三分之一的急性重度溃疡性结肠炎（ASUC）患者对类固醇治疗无效。我们旨在回顾类固醇难治性 ASUC 的不同治疗选择，不仅包括标准治疗[环孢素和英夫利昔单抗]，还包括最近开发的药物[如维得利珠单抗、乌司奴单抗和托法替布]。
我们进行了文献检索，以确定专注于治疗类固醇难治性 ASUC 的研究。
环孢素和英夫利昔单抗目前是挽救治疗的主要药物，它们通常被认为是等效的。然而，英夫利昔单抗治疗的长期持续率更高，许多临床医生更喜欢使用英夫利昔单抗，因为它使用方便。然而，环孢素的成本较低。在转诊中心，对于高度选择的病例，可以考虑在环孢素或英夫利昔单抗治疗失败后进行序贯解救治疗[分别使用英夫利昔单抗和环孢素]。由于其快速作用，托法替布是一种有吸引力的解救选择，主要适用于生物制剂经验丰富的患者。维得利珠单抗和乌司奴单抗良好的安全性使其成为与环孢素联合作为诱导治疗的维持治疗的理想候选药物，特别是对于先前暴露于抗 TNF 或硫唑嘌呤的患者。
虽然环孢素和英夫利昔单抗仍然是类固醇难治性 ASUC 挽救治疗的主要药物，但新的治疗药物也可能发挥作用。由于其快速作用，托法替布是一种有吸引力的治疗解救选择。维得利珠单抗和乌司奴单抗作为与快速起效的环孢素联合作为诱导治疗的维持治疗，可能是一种有前途的桥接策略，特别是对于先前对硫唑嘌呤和/或抗 TNF 药物治疗失败的患者。
