He was started on IV methylprednisolone 40-60mg daily, with significant improvement in his bloody stools within 48 hours. He was transitioned to PO prednisone 40mg daily and discharged from the hospital on day 4.
What therapy would you recommend for maintaining remission?
Delayed release mesalamine 4.8g PO daily
Mesalamine based therapies would not be expected to be potent enough to treat this patient’s moderate to severe ulcerative colitis
Prednisone 40mg PO Daily
The many side effects of prolonged gluccocorticoid use including diminished bone health, immunosuppression, iatrogenic diabetes, weight gain, hirsutism, and fluid retention make this a poor choice for maintenance therapy.
Vedolizumab
Head to head trial between Vedolizumab and Adalimumab in patients with moderate to severe ulcerative colitis showed 52 week clinical remission outcomes favoring Vedolizumab. In this elderly patient, the side effect profile of vedolizumab may support vedolizumab over infliximab
Adalimumab
Head to head trial between Vedolizumab and Adalimumab in patients with moderate to severe ulcerative colitis showed 52 week clinical remission outcomes favoring Vedolizumab.
Infliximab
A 2020 network meta-analysis favored infliximab 5-10mg/kg as the most effective agent. However, its side effect profile including immunosuppression and potential for exacerbation of heart failure should be taken into account
Ustekinumab
Current data supports ustekinumab as an alternative agent for this patient given its more favorable side effect profile and efficacy
Tofacitinib
Data support tofacitinib as a first line therapy, however due to safety concerns, it is used only for those who fail anti-TNF therapy.
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