Yes, We Are Still Talking about Cylosporin vs. Infliximab in Steroid Resistant Acute Severe Ulcerative Colitis

Abstract

The Spanish IBD Registry (ENEIDA) is reporting in this issue of the Journal on a retrospective assessment of outcomes of cyclosporine use and infl iximab use to treat steroid refractory acute severe ulcerative colitis (SR-ASUC) between 1989 and 2013. Overall, they found similar outcomes in terms of 3 month and 1 year colectomy rates. Serious adverse events were lower in cyclosporine users. While this study does not meet the standard of a prospective randomized controlled trial, it does remind us that cyclosporine can be effective in (SR-ASUC) and should be considered in those who have already failed antibody to tumor necrosis factor therapy or as a bridge to immunomodulators that have a slower onset of action.

Optimal Management of Acute Severe Ulcerative Colitis (ASUC): Challenges and Solutions

“…Despite its methodological issues, this large cohort again showed no difference in colectomy rate between cyclosporin and infliximab therapy (respectively 19.6% and 23.6%, p=0.57 at 1 year) with severe adverse events and infection being more common in the infliximab group. 34,35 However, a recent prospective cohort study in 55 ASUC patients showed higher endoscopic remission rates in infliximab treated patients compared to patients treated with cyclosporine (73% vs 25%). 36 Korean ASUC patients treated showed better colectomy rates with infliximab then previously described (eg, 6.9% at 3 months and 18.1% at a mean follow-up of 69 months).…”

Management of Hospitalized Patient with Ulcerative Colitis Refractory to Corticosteroids

“…In the multivariate analysis, the use of two or more of these agents in addition to CyA was associated with a significantly higher rate of opportunistic infection (OR 14.5, 95% CI 4.9-43) compared to only one additional agent (OR 2.9, 95% CI 1.5-5.3) [27,34]. Furthermore, total cholesterol should be greater than 170 to avoid 3% risk of seizures with drug administration [6,35]. Given these side effects, CyA needs to be used with caution, carefully monitoring serum CyA levels and renal function as well as for potentially life-threatening infectious complications.…”

“…Check levels at 2 weeks, and if less than 25, consider administering the third induction dose at week 4 instead of week 6. Consider adding a thiopurine when the steroid dose has been reduced below 20 mg. Plan to keep him on the thiopurine for less than 2 years as the risk of hepatosplenic T cell lymphoma is highest in his demographic (males <age 35).…”