Tofacitinib for Rescue Therapy in Acute Severe Ulcerative Colitis: A Real-world Experience

Abstract

Background Acute severe ulcerative colitis is a high stakes event with significant numbers still requiring emergent colectomy, representing a need to establish alternative medical management options. We report a case series of tofacitinib as rescue therapy in biologic-experienced patients with acute severe ulcerative colitis. Methods Four patients were identified over a 1-year period at our institution who initiated tofacitinib for acute severe ulcerative colitis. All four had previously failed at least two biologics, including infliximab, and were failing high-dose oral prednisone therapy before admission. All patients had Mayo disease activity index of at least 10 at admission. After no significant improvement despite receiving a minimum of 3 days of intravenous methylprednisolone and based on elevated Ho and Travis indices at Day 3, patients were offered rescue tofacitinib for induction of remission, or colectomy. Standard induction of tofacitinib was used [10 mg twice daily], and one patient was escalated to 15 mg twice daily after inadequate response. Results All patients experienced improvement in objective symptoms and laboratory markers, and were discharged without colectomy on tofacitinib as maintenance therapy and prednisone taper; 30-day and 90-day colectomy rates on tofacitinib maintenance therapy were zero and 90-day readmission rate was also zero. Two of four patients achieved steroid-free remission on maintenance tofacitinib monotherapy based on clinical symptoms and follow-up endoscopy. No major adverse reaction was reported during induction or maintenance therapy. Conclusions Tofacitinib may be an acceptable rescue agent in biologic-experienced patients with acute severe ulcerative colitis. Tofacitinib may also be safely continued as maintenance therapy once remission has been achieved.

Adaptations to the British Society of Gastroenterology guidelines on the management of acute severe UC in the context of the COVID-19 pandemic: a RAND appropriateness panel

“…45 There is also very limited evidence for its use in the setting of ASUC. 46 For these reasons, the panel considered its use inappropriate in nearly all settings although it was noted that its rapid offset of action could be of theoretical benefit.…”

Long-term outcomes of infliximab in a real-world multicenter cohort of patients with acute severe ulcerative colitis

“…Further clinical trials with different biologics or small molecules are also needed in this setting. 32,33 In conclusion, we have reported the favorable short-term and long-term outcomes of IFX treatment in Korean patients with ASUC, pointing to IFX as an effective therapeutic option in such a critical situation. We believe that IFX can be considered as a first-line option for the treatment of ASUC, in highly selected patients, who cannot receive initial therapy with IVCS.…”

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

“…67 In another case series of again only 4 patients all patients achieved remission, and no one had to undergo colectomy. 68 In a recent case series of 5 ASUC patients who had failed anti-TNF therapy, 3 improved under tofacitinib therapy while 2 eventually had to undergo acolectomy. 69 Further prospective studies are needed.…”