Steroid / thiopurine refractory UC

  • Steroid-refractory disease includes relapse within 3 months of steroid-induced remission

Steroid or thiopurine refractory disease

  • Confirm disease activity (biomarkers incl. calprotectin).

  • Exclude infection due to C. difficile.

  • Consider endoscopy to assess activity, and exclude CMV, and cancer.

Assess disease extent and activity

  • Continue thiopurine for a total of 3 months to determine if responsive disease

  • Treat left-sided and extensive mild colitis

  • Escalate from failed therapies in the context of disease activity

Treat appropriately

ECCO statement 11K (UC 2017)

Patients with moderate colitis refractory to thiopurines should be treated with anti-TNF [EL1], preferably combined with thiopurines, at least for infliximab [EL2], or vedolizumab [EL2]. In case of treatment failure, a different anti-TNF [EL4] or vedolizumab [EL2] should be considered, and colectomy recommended if further medical therapy does not achieve a clear clinical benefit [EL5]

ECCO statement 12I (UC 2017)

Anti-TNF or vedolizumab may be used as first-line biological therapy. Vedolizumab is effective in patients failing anti-TNF [EL2]. In patients responding to vedolizumab, maintenance therapy with vedolizumab is appropriate [EL2]

Further information

  • Anti-TNF + thiopurines provide steroid free remission in 40% at 4 months, and 25% at 1 year

  • It is unclear whether thiopurines should be continued if previously thiopurine-refractory, in which case methotrexate may have a role

  • Limited data for tacrolimus. Vedolizumab is a valid therapy

Anti-TNF or Vedolizumab

  • Continue anti-TNF ± thiopurine

  • Consider stepping down to thiopurine maintenance therapy in those previously thiopurine-naïve with sustained deep remission

Continue therapy

Optimise therapy

  • Consider semi-elective colectomy (no treatment achieves steroid free remission in the majority)


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