Patients with Acute Severe Ulcerative Colitis May Benefit from Longer Corticosteroid Tapering Time, Study Finds

Ulcerative colitis is a chronic inflammatory disease characterized by alternating periods of symptom flare-ups and remission. Treatment goals are aimed at inducing and maintaining remission. Corticosteroids are among the recommended therapies for moderate to severe flare-ups.

For patients with frequent symptom flare-ups or whose condition does not respond to corticosteroids (steroid-refractory), biologics such as the tumor necrosis factor (TNF) inhibitor infliximab are recommended.

Treatment guidelines recommend using infliximab or cyclosporine for patients with steroid-refractory acute severe UC. In some cases, corticosteroid treatment may overlap with infliximab therapy as the steroid is tapered. However, little is known about the effect of different corticosteroid tapering regimens on the outcomes of infliximab treatment in patients with UC.

In a study recently published in BMJ Open Gastroenterology, researchers led by Pernille Dige Ovesen from the department of gastroenterology and hepatology in Copenhagen University Hospital investigated the effect of concomitant corticosteroid therapy on treatment outcomes in patients with UC initiating infliximab. The investigators conducted a retrospective chart review of data from the biobank of a tertiary inflammatory bowel disease center in Denmark.

The study’s primary endpoints were the proportion of patients who reached clinical and biochemical (measured by C reactive protein levels) corticosteroid-free remission at 14 weeks and clinical remission at 52 weeks. A total of 147 patients with UC who received infliximab between 2009 and 2019 were included in the study.

The cohort was divided into four groups:

1. Patients who underwent standard prednisolone tapering (by 5 mg or less per week).
2. Those who underwent fast tapering (by more than 5 mg per week).
3. Patients who discontinued prednisolone at the start of infliximab therapy with no tapering.
4. Those who received infliximab monotherapy (no corticosteroid).

The researchers found no significant difference in the proportion of patients who achieved corticosteroid-free clinical remission at weeks 14 or 52 between the different tapering regimens or the infliximab monotherapy groups. However, a subgroup analysis showed that in patients with acute severe UC, nearly 90% of those in the standard tapering group were in clinical remission after 52 weeks versus about 35% of patients who underwent fast corticosteroid tapering.

Ovesen and his colleagues note that a more prolonged corticosteroid exposure may boost the effectiveness of infliximab in patients with high disease burden. However, infection rates were significantly higher in the prednisolone-treated group compared with the no prednisolone group. C. difficile infections accounted for 70% of all the reported infections.

The authors conclude that there is no association between the length of prednisolone treatment or tapering regimen and the effectiveness of infliximab in UC patients with limited disease burden. However, patients with a high disease burden may benefit from longer corticosteroid tapering during infliximab initiation.