Commentary: short‐term efficacy of tacrolimus in steroid‐refractory ulcerative colitis

Abstract

The medical management of patients with refractory ulcerative colitis (UC) remains a significant challenge. Up to one-third of patients with UC require surgery. Immunomodulators are fundamental in the management of refractory UC. However, a proportion of patients are unresponsive to, or intolerant of, thiopurines. Data for other medical options are limited, with serious potential adverse effects. Further data for other pharmacological agents are needed for these patients. Two randomised studies 4 demonstrate the efficacy of tacrolimus in the induction of remission of moderate to severe UC in hospitalised patients at 2 weeks. Only small retrospective analyses have assessed longer term outcomes following tacrolimus treatment for this group. 6 Additional evidence is necessary regarding the efficacy of tacrolimus for steroid-refractory UC beyond the first few weeks of treatment. Schmidt et al. report a large retrospective study conducted across three centres of 130 patients with moderate to severe UC treated with tacrolimus. Clinical remission was achieved in 72% of patients after 3 months. Remission was achieved significantly more frequently in patients concomitantly treated with a thiopurine. Fourteen per cent of patients underwent colectomy within 3 months of initiating tacrolimus treatment. Adverse effects were observed in over half of the patients, but only in two cases was tacrolimus discontinued with no opportunistic infections or deaths occurring. This study is subject to the limitations of retrospective data. One-third of patients were treated de novo with a thiopurine concomitantly, data regarding patients’ tacrolimus levels are limited and other biological and endoscopic data are not presented. However, it provides an evaluation of a large group of patients with steroidrefractory UC treated with tacrolimus, with promising short-term outcomes, although longer term outcomes with tacrolimus in UC remain unclear.