Infliximab rescue therapy in acute severe ulcerative colitis: more does not equal better

The pursuit of inflammation control in acute severe ulcerative colitis (ASUC) over the past 70 years has witnessed three distinct eras: the steroid era (oral and intravenous) pioneered by Truelove and Witts, which was a key step in reducing ASUC-associated mortality, yet left around a third of patients with inflamed colons; the era of medical rescue therapy (infliximab and ciclosporin), which salvaged steroid non-responders, but with colectomy rates plateauing at 10–13%; and the present third era of predictive models and novel dosing strategies, ambitiously aiming to establish supremacy of medical therapy and eliminate the need for colectomy. As discussed in a recent review, these three eras have so far encompassed 33 randomised controlled trials (RCTs) investigating 23 distinct therapies, yet around 15% of patients have persistent inflammation despite targeted medical therapy.1