Management of Steroid-Dependent Ulcerative Colitis: Immunomodulatory Agents, Biologics, or Surgery?

A 32-year-old woman with moderate pancolonic UC diagnosed 1 year ago makes an office appointment because she is unable to discontinue prednisone without experiencing a flare. At diagnosis, her symptoms improved within 2 weeks with 5-aminosalicylate therapy. Despite ongoing therapy with 5-aminosalicylates, she has experienced 2 moderate disease exacerbations requiring use of prednisone. Since her last flare 4 months ago, she has been unable to successfully reduce her prednisone below 10 mg per day without experiencing an increase in symptoms. On lower doses, she experiences abdominal cramping, an increase in bowel movements to 6 per day, urgency, and blood in the stool. Evaluation to date has consisted of a recent flexible sigmoidocopy showing mild to moderate mucosal inflammation to the descending colon, negative mucosal viral cultures for cytomegalovirus, and negative stool studies for bacteria, parasites, and Clostridium difficile toxin. Complete blood count and albumin are normal. She tells you that she is concerned about the cosmetic side effects of prednisone and the health effects of colitis impacting her upcoming wedding in 9 months. Since starting prednisone, she has experienced a 15-pound weight gain, as well as acne, insomnia, and fatigue. She requests a referral to a surgeon. She believes that “pouch surgery” is the only way she will be able to discontinue prednisone and be healthy for her wedding and married life.

Abbreviations used in this paper: ACT, Active Ulcerative Colitis Trial, AZA, azathioprine, FDA, Food and Drug Administration, IPAA, ileal pouch–anal anastomosis, 6MP, 6-mercaptopurine, QOL, quality of life, TPMT, thiopurine methyltransferase, UC, ulcerative colitis