Management of Ulcerative Colitis Flares with Prednisolone and Infliximab

Introduction to Combination Therapy

• The European Crohn’s and Colitis Organisation recommends prednisolone for induction of remission in moderate to severe ulcerative colitis, which can be effectively combined with biologic agents like infliximab 1
• The American Gastroenterological Association suggests that the combination of infliximab plus immunomodulators can be superior to either agent alone, with corticosteroid-free remission at Week 16 achieved by 39.7% of patients receiving combination therapy compared to 22.1% with infliximab alone 2, 3

Management Algorithm for UC Flares

• For moderate to severe UC flares, the British Society of Gastroenterology recommends prednisolone (40-60 mg/day) for induction of remission, with a strength of evidence level of 1A 1
• The American College of Gastroenterology suggests continuing infliximab at the regular dosing schedule as maintenance therapy, with a moderate level of evidence 2
• The European Crohn’s and Colitis Organisation recommends monitoring for clinical response within 2 weeks of starting prednisolone, with a high level of evidence 1

Tapering Strategy and Maintenance

• The American Gastroenterological Association recommends reducing prednisolone gradually according to severity and patient response, generally over 8 weeks, with a low level of evidence 4
• The British Society of Gastroenterology suggests that corticosteroids are not recommended for long-term maintenance therapy due to significant adverse effects, with a high level of evidence 4
• The American College of Gastroenterology recommends continuing infliximab as the maintenance agent after successful induction with the combination therapy, with a moderate level of evidence 1

Follow-up Considerations and Special Situations

• The European Crohn’s and Colitis Organisation suggests that if there is no adequate response to oral corticosteroids within 2 weeks, consider adjusting the biologic therapy or adding an immunomodulator, with a moderate level of evidence 1
• The American Gastroenterological Association recommends that for maintenance, purine analogues (like azathioprine) can be used alongside infliximab therapy, with a low level of evidence 1
• The American College of Gastroenterology suggests avoiding long-term corticosteroid use, as corticosteroids should never be used for maintenance therapy due to significant adverse effects, with a high level of evidence 4
• The British Society of Gastroenterology recommends considering combination with immunomodulators, as adding azathioprine to infliximab may improve outcomes further, as demonstrated in the UC-SUCCESS trial, with a moderate level of evidence 2, 5
• The European Crohn’s and Colitis Organisation suggests monitoring for infections, as the combination of biologics and corticosteroids increases infection risk, requiring careful monitoring, with a high level of evidence 6
• The American Gastroenterological Association recommends that steroid-free remission should be the goal, as studies show that infliximab can help achieve steroid-free remission in 21.5% of patients by Week 30, compared to 7.2% with placebo, with a moderate level of evidence 3
• The American College of Gastroenterology suggests individualized dosing, as the optimal prednisolone dose is 40-60 mg/day, with higher doses not showing additional benefit but potentially increasing adverse effects, with a high level of evidence 1
• The British Society of Gastroenterology recommends that for patients who have frequent flares requiring repeated courses of corticosteroids, consider optimizing the infliximab regimen or adding an immunomodulator, with a moderate level of evidence 1, 5
• The European Crohn’s and Colitis Organisation suggests that for patients with acute severe UC not responding to intravenous corticosteroids, infliximab is suggested as a rescue therapy, with a high level of evidence 7