Review article: saving the colon in severe colitis - the case for medical therapy.

The choice between ciclosporin (CsA), infliximab (IFX) and surgery for severe colitis not responding to intensive intravenous treatment, is challenging. With the advent of vislizumab and alternatives such as tacrolimus or leucocytapheresis, decisions will get harder. This article reviews the evidence for each intervention, draws attention to disparities in the definition of severe colitis between different trials and gives practical guidance. Early medical decision making is critical. Standard intensive treatment with intravenous steroids is still the first-line approach. Progress should be monitored objectively using a simple predictive index. Rescue therapy with CsA (oral 5 mg/kg or 2 mg/kg iv) or IFX (5 mg/kg) should be started on the third day of intensive treatment if predictive factors are poor (e.g. C-reactive protein > 45 mg/L). Physicians should discuss with their patients that there is just one attempt at rescue therapy, because only one patient death, as a consequence of delayed colectomy, changes the balance of benefit between medicine and surgery.