We read with interest the recently published study performed by Kumar et al., examining rates of clinical remission at 6 months with differing tapering regimes of corticosteroids in moderate to severe acute ulcerative colitis 1. This is an important study, as currently there remains a paucity of data to define the optimal steroid tapering regimen in moderate to severe ulcerative colitis. We had a few observations that we wish to convey to help interpret the study. Firstly, this study included both patients requiring intravenous steroids with subsequent switch to oral tapering as well as those initiating just oral corticosteroids. We believe these are likely to represent different and distinct patient cohorts. It would perhaps be interesting to see these as separate analyses in future studies. These factors may have an impact on relapse rate, remission and approach to dosing and selection of azathioprine or 6MP medical therapy. Secondly, it should also be noted that some patients at the commencement of the study in both arms did not have their disease extent evaluated. This is likely to have an impact on disease outcomes, with more extensive disease likely requiring more aggressive therapy. In this study, patients who were hospitalised were randomised into either arm of the cohort, having received either 100 mg intravenous hydrocortisone four times a day or 60 mg intravenous methylprednisolone (IVMP) daily for 5 days. The literature appears insufficient on whether these two medications are equivalent in efficacy in this particular patient cohort. One study from Schauer et al. suggests treatment with IVMP results in significantly more requirements for inpatient rescue biologic therapy, which may be a signal towards potential inferiority 2. Though a minor consideration, these differences may also culminate in differences in outcomes. Thirdly, the use of concomitant medications is likely to be important confounders. Both arms of this study received oral mesalamine with or without rectal preparation, though dosing was not clearly defined for each arm. A higher dose may have conferred an additional clinical benefit. Critically, Azathioprine and thiopurines can take up to 3 months to provide clinical benefit 3. As such, this concomitant therapy is likely to show greater benefit in the longer taper arm and, therefore, may be a key confounder for these findings. In addition, thiopurine metabolites were only performed for two-thirds (66%) of the LTA and just over three-quarters in the STA (76%), and therefore it is difficult to interpret how many of these were at therapeutic levels contributing to 6-month remission rates. To conclude, a shorter course of corticosteroid (in the case of this study, 6 weeks) is likely to be inferior to longer courses. However, we would welcome consideration of the above factors when interpreting this study and believe that further validation studies that take these factors into account would help support these findings. Glen Saward: writing – original draft, writing – review and editing. Jonathan Segal: conceptualization, writing – review and editing, supervision. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to Kumar et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70509. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Saward et al. (Wed,) studied this question.