Clinical bottom line
Acute severe ulcerative colitis (ASUC) remains a medical emergency requiring prompt, evidence-based intervention to reduce morbidity and avoid colectomy. Recent advances emphasize early risk stratification, optimized corticosteroid protocols, and timely escalation to biologic or calcineurin inhibitor therapies for steroid-refractory cases. Nutritional support and multidisciplinary care are increasingly recognized as integral components. While infliximab and cyclosporine remain mainstays for rescue therapy, emerging data suggest that newer biologics and small molecules may offer alternative options, though their precise roles require further validation. Pediatric-specific guidelines now provide tailored recommendations reflecting differences in disease course and treatment response. Overall, management continues to evolve toward personalized, protocol-driven care to improve short- and long-term outcomes (Ong et al., 2024; Assa et al., 2025).
What the evidence shows
The cornerstone of ASUC management is intravenous corticosteroids, typically methylprednisolone or hydrocortisone, administered promptly upon diagnosis. Approximately 60-70% of patients respond to steroids; however, early identification of steroid non-responders is critical to avoid delays in rescue therapy (Jani et al., 2024; Kedia et al., 2014). Clinical scoring systems such as the Travis criteria and the Oxford index remain useful tools for risk stratification.
For steroid-refractory ASUC, infliximab and cyclosporine are the most studied rescue therapies. Infliximab has demonstrated efficacy in inducing remission and reducing colectomy rates, with dosing strategies now favoring accelerated or intensified regimens in severe cases (Ong et al., 2024; Laharie et al., 2023). Cyclosporine remains an alternative, particularly when biologics are contraindicated or unavailable, but requires careful monitoring due to toxicity risks (Fudman et al., 2025).
Emerging therapies, including vedolizumab and tofacitinib, show promise but lack robust data in the acute severe setting, warranting cautious consideration and further study (Fudman et al., 2025). Nutritional management, often overlooked, is gaining recognition for its role in supporting mucosal healing and reducing complications; exclusive enteral nutrition or tailored supplementation may be beneficial adjuncts (Amir et al., 2026).
Pediatric guidelines from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Crohn’s and Colitis Organisation (ECCO) emphasize early multidisciplinary involvement, standardized steroid protocols, and timely escalation to biologics, reflecting differences in disease phenotype and treatment response compared to adults (Assa et al., 2025; Wine et al., 2025).
Caveats and uncertainty
Despite advances, several uncertainties remain. The optimal timing and dosing of rescue biologics in ASUC are not fully established, with heterogeneous study designs and patient populations limiting definitive conclusions (Ong et al., 2024). Long-term comparative effectiveness and safety data for newer agents in this setting are lacking. Nutritional interventions, while promising, have limited high-quality evidence specific to ASUC and require validation in controlled trials (Amir et al., 2026).
Pediatric data are more limited than adult studies, and extrapolation must be cautious given differences in pharmacokinetics and disease course (Assa et al., 2025). Furthermore, the impact of emerging small molecules and combination therapies on infection risk and immunosuppression in the acute severe setting warrants careful monitoring.
Finally, the role of early surgery versus medical rescue therapy remains a clinical judgment call, balancing risks of colectomy against prolonged immunosuppression, with no universally accepted algorithm.
How this may change practice
Clinicians managing ASUC should adopt protocolized approaches incorporating early risk stratification tools to identify steroid non-responders within 3-5 days and escalate therapy promptly. Accelerated infliximab induction regimens may be considered for selected patients with severe disease or high inflammatory burden. Cyclosporine remains a viable alternative in specific contexts but requires expertise in monitoring.
Nutritional assessment and support should be integrated into routine care pathways, with multidisciplinary teams including dietitians engaged early. Pediatric gastroenterologists should follow updated ESPGHAN/ECCO consensus guidelines to optimize outcomes in children.
Emerging therapies should be considered experimental in ASUC until further evidence accrues, ideally within clinical trials or registries. Shared decision-making regarding timing of surgery versus continued medical therapy remains essential, with individualized risk-benefit assessments.
Overall, these advances underscore the importance of timely, personalized, and multidisciplinary management strategies to improve ASUC outcomes.