We thank Dr. Bhat and Dr. Shetty for their interest in our randomised trial on tapering of steroids in ulcerative colitis and their insightful comments 1, 2. Only a small fraction of patients enrolled in the study were already on azathioprine and these were included only if the dose being used was suboptimal (40.6 ± 17.4 mg vs. 41.7 ± 11.8 mg) in the long versus short taper arm. As we have indicated, most patients were started on thiopurines during this study (> 80%) at the discretion of treating clinicians. As we have argued previously in the manuscript, the benefit of the longer taper of steroids may be related to the slow onset of action of thiopurines which is relevant to the context and setting of this trial 3. Regarding use of a 6 month window for assessing outcomes, we respectfully disagree that this is suboptimal: the impact of steroid cessation and ongoing maintenance therapy would be evident by this time, and longer follow-up would inevitably increase dropouts and other factors creeping in distorting the results. We also disagree with the need to shift to other therapies in patients who have achieved a steroid free clinical remission: obviously those with flares received additional therapies (steroids/advanced therapy/surgery). The authors also cite guidelines to suggest a shorter course: unfortunately, these recommendations are all expert consensus and not based on evidence. We do agree with authors that lack of previous steroid exposure was not factored in the randomisation although this informed our choice of thiopurine use (especially if this was second course of steroids or higher). Regarding the availability of small molecules, the authors appear to confuse the current situation in India, thanks to the availability of generics, to rest of the world 4, 5. Most advanced therapies remain unavailable or unaffordable to most of the world and extremely costly even in the West. Nevertheless, by the time this trial was designed, there was a lack of availability of small molecules and the data on the use of small molecules as first line advanced therapy were still emerging 6. Till these therapies become accessible to one and all, the combination of steroid plus 5-aminosalicylate based induction with thiopurine plus 5-aminosalicylate based maintenance will continue to be used across the globe. Amol N. Patil: writing – review and editing. Vishal Sharma: writing – review and editing, writing – original draft. Ankit Kumar: writing – review and editing. The authors have nothing to report. This article is linked to Kumar et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70509 and https://doi.org/10.1111/apt.70546. The authors have nothing to report.
Patil et al. (Thu,) studied this question.