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Acute severe ulcerative colitis (ASUC) remains one of the challenging presentations in inflammatory bowel disease (IBD) where progress on therapeutic approaches has been limited since 1955 when corticosteroids revolutionised care 1 to reduce the mortality associated with ASUC. Despite the advent of rescue therapy options, short- and long-term colectomy rates remain stubbornly high2 . While newer strategies to reduce the need for in-hospital colectomy during an index admission are being considered with variable success, there is limited data guiding the management of steroid-responsive patients with ASUC. In GUT, Amiot et al 3 aimed to address this gap in knowledge by randomising ASUC patients responding to intravenous steroids (IV) to infliximab with azathioprine (IFX+AZA) or azathioprine (AZA) alone. The results indicate a 28% reduction in treatment failure at week 52, defined as the composite of the absence of steroid-free clinical remission and endoscopic response or the use of a prohibited treatment for relapse or severe adverse event leading to treatment interruption, colectomy or death. Based on their results, the authors propose a top-down approach to treating ASUC patients.
This is a pivotal trial in one of the orphan areas in IBD. Does this change practice? Potentially yes, as this study challenges the prior recommendations4 to use thiopurines as maintenance, and the authors suggest incorporating the initiation of advanced therapies in all ASUC patients. Furthermore, this study gives further evidence that ASUC is a severe disease and may need early proactive advanced therapies. The key takeaway is whether the study has generated enough evidence to warrant a change in treatment guidelines. The goalpost has been possibly missed if looking at the possible confounders in the study that may have preferentially supported the combination of infliximab and azathioprine while disadvantaging azathioprine monotherapy. These confounders include (i) patient inclusion based on …
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Collaborators Conflicts of interest: SS: Received consulting fees from Takeda, AbbVie, Merck, Ferring, Pharmacosmos, Warner Chilcott, Johnson & Johnson Innovative Medicine, Dr Falk Pharma, Biohit, TriGenix, Celgene, and Tillots Pharma outside the submitted work; payment or honoraria from AbbVie, Takeda, Celltrion, Pfizer, Biogen, AbbVie, Johnson & Johnson Innovative Medicine, Merck, Warner Chilcott, and Dr Falk Pharma outside the submitted workVA: Nil AS: Nil.
Contributors This is an invited editorial. All authors contributed to writing the editorial and proofread and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests SS: received consulting fees from Takeda, AbbVie, Merck, Ferring, Pharmacosmos, Warner Chilcott, Johnson & Johnson Innovative Medicine, Dr Falk Pharma, Biohit, TriGenix, Celgene and Tillots Pharma outside the submitted work; payment or honoraria from AbbVie, Takeda, Celltrion, Pfizer, Biogen, AbbVie, Johnson & Johnson Innovative Medicine, Merck, Warner Chilcott and Dr Falk Pharma outside the submitted work. VA: nil. AS: nil.
Provenance and peer review Commissioned; internally peer reviewed.
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