High-Dose Rescue Tofacitinib Prevented Inpatient Colectomy in Acute Severe Ulcerative Colitis Refractory to Anti-TNF

To the editors, Acute severe ulcerative colitis (ASUC), as defined by the Truelove-Witts criteria,1 is a medical emergency. The mainstay of treatment remains hospitalization, exclusion of infection, high-dose intravenous steroids, medical rescue with infliximab/cyclosporine in patients who do not respond, or colectomy.2 However, in patients with previous failure with infliximab, there is no medical treatment in the hospitalized setting with proven efficacy, and major safety concerns have been noted using sequential-medical therapy with cyclosporin/infliximab.3 Although several agents are approved for the treatment of moderate-to-severe ulcerative colitis (UC), including vedolizumab (anti-integrin), tofacitinib (oral Janus-kinase inhibitor), and ustekinumab (interleukin-12/23 antagonist), none have proven efficacy for ASUC.4 We present a report of a male patient dependent on steroids with severe UC and oral ulceration, refractory to high-dose infliximab, and hospitalized with ASUC who was successfully rescued with high-dose, off-label tofacitinib before a successful transition to standard dosing, achieving clinical,...