Frontiers in the management of acute severe ulcerative colitis: current best practice and future directions

Acute severe ulcerative colitis (ASUC) remains a medical emergency with significant risks of colectomy and mortality. Its management continues to rely on treatment pathways that have changed little over the last two decades despite major advances in ulcerative colitis therapeutics. Intravenous corticosteroids remain the cornerstone of initial inpatient management; however, up to one-third of patients do not respond adequately and require escalation to medical or surgical rescue. Despite these approaches, the requirement for colectomy has improved only modestly.

This narrative review summarises current best practice in the diagnosis and inpatient management of ASUC, with a focus on pragmatic real-world decision-making for practising gastroenterologists. We describe the emerging concepts in rescue therapy strategies in corticosteroid non-responders and in particular the timing and dosing schedule of infliximab.

In addition, we explore other approaches including use of Janus kinase inhibitors, adjunct therapies, sequential salvage strategies and dual-targeted approaches. We evaluate the developments in predictive risk tools, novel biomarkers and use of intestinal ultrasound. Ongoing clinical trials may enable a future shift in the management of ASUC from the current three-step escalation pathway towards a future personalised risk-based treatment approach.