Review suggests infliximab superior to cyclosporine for acute severe ulcerative colitis

Infliximab may be more effective than cyclosporine in treating acute severe ulcerative colitis (UC), while Janus kinase (JAK) inhibitors are promising treatment options for patients with corticosteroid-refractory acute severe UC, according to a systematic review and meta-analysis.

To assess the efficacy and safety of treatments for hospitalized patients with UC, researchers searched databases for randomized controlled trials and comparative cohort studies. Primary outcomes were colectomy rates at discharge and at three and 12 months, and safety outcomes included adverse events, serious adverse events, and infections. A total of 44 studies (18 randomized controlled trials, 26 cohort studies) that assessed 22 different comparisons in 7,675 participants were included. Findings were published by Clinical Gastroenterology and Hepatology on May 6.

Researchers found low-certainty evidence that infliximab was superior to cyclosporine for reducing the risk of colectomy at discharge (risk ratio [RR], 0.56; 95% CI, 0.38 to 0.81), three months (RR, 0.67; 95% CI, 0.48 to 0.92), and 12 months (RR, 0.56; 95% CI, 0.42 to 0.75). Patients taking infliximab were significantly more likely to develop an infection than those taking cyclosporine (RR, 2.38; 95% CI, 1.27 to 4.47). No differences were seen between accelerated and standard dosing of infliximab on the outcome of colectomy at discharge or at three months. The study also found that at day seven, tofacitinib in combination with IV corticosteroids was significantly superior to IV corticosteroids alone for induction of clinical response, but there was no difference in colectomy rate or infections at three months.

Limitations to the study include the absence of research on nutritional interventions and interventions requiring devices. Most included studies were also observational, with the certainty of evidence for primary outcomes judged to be low to very low. The definition of an accelerated or intensified dosing schedule of infliximab was also inconsistent across studies.

According to the authors, the results emphasize the limited effective treatment options for this condition and highlight the need for more research. “Janus kinase (JAK) inhibitors represent a promising rescue therapy for select individuals with corticosteroid refractory [acute severe] UC. Future studies should explore the efficacy of long-acting agents such as ustekinumab and vedolizumab as maintenance therapies,” they concluded.