Calcineurin Inhibitors or Anti-TNF-α Agents in Severe Ulcerative Colitis: Available Options and Limitations

Abstract

A majority of patients with ulcerative colitis (UC) respond to medical therapy and remain in remission. However, approximately 20 % of UC patients experience severe relapses that require hospitalization. For these cases, intravenous corticosteroids are the established first-line treatment and 70 % of patients respond. Patients who do not respond to corticosteroids within 48 to 72 hours should receive calcineurin inhibitors, anti-TNF-α therapy or total proctocolectomy, which must be selected based on clinical, endoscopic and laboratory parameters and patient preference. The selection of second-line medical therapy after steroid failure, surgery and the benefits of medical salvage therapy following second-line therapy failure represent current challenges in the treatment of acute steroid-refractory colitis. Patients and physicians must realize that immunosuppressive therapies, especially in combination, bear the risk of serious and fatal infections. Therefore, decisions regarding short- and long-term treatment strategies must consider the efficacy and potential toxicity of pharmacological interventions and the quality of life after restorative proctocolectomy with ileal pouch-anal anastomosis.

Zusammenfassung

Bei der Mehrzahl der Patienten mit Colitis ulcerosa (CU) kann durch eine medikamentöse Behandlung der akute Schub behandelt und eine stabile Remission induziert werden. Ca. 20 % der Patienten erleiden im Verlauf einen schweren, teilweise fulminant-verlaufenden Schub, der eine stationäre Behandlung notwendig macht. In diesen Fällen ist die intravenöse Steroidtherapie Ansatz der 1. Wahl; bei 70 % der Patienten kann so eine Besserung erreicht werden. Kommt es jedoch innerhalb von 48 − 72 h nicht zu einer Besserung, ist die Therapie mit Calcineurin-Inhibitoren (Cyclosporin A, Tacrolimus), anti-TNF-α-Antikörpern oder die (Prokto-)Kolektomie zu wählen. Diese Entscheidung hängt von klinischen, endoskopischen und laborchemischen Befunden und dem Patientenwunsch ab. Dabei muss der Nutzen einer medikamentösen Erstlinientherapie mit den Möglichkeiten/Limitationen einer medikamentösen Reservetherapie und dem chirurgischen Eingriff verglichen werden. Patienten und Ärzte müssen realisieren, dass eine immunsuppressive Kombinationstherapie schwere Komplikationen, insbesondere Infektionen bedingen kann. Vor diesem Hintergrund sind die Entscheidungen für deutlich effektivere kurz- und langfristige konservative Therapiekonzepte mit dem Ziel der Remissionsinduktion bzw. dem Remissionserhalt, deren potenziellen Nebenwirkungen und der Lebensqualität nach Proktokolektomie mit ilioanaler Pouchanlage abzuwägen.

Key words

bowel - chronic inflammatory bowel disease - ulcerative colitis

Schlüsselwörter

Darm - chronisch entzündliche Darmerkrankung - Colitis ulcerosa

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