S1574 Choosing the Right Rescue: A Meta-Analysis of Infliximab vs Cyclosporine in Steroid-Refractory Acute Severe Ulcerative Colitis

Introduction: Acute Severe Ulcerative Colitis (ASUC) is a fulminant manifestation of ulcerative colitis associated with complications such as colonic perforation, massive hemorrhage, emergent colectomy, and death. Management strategies have progressed from supportive measures and intravenous steroids to rescue therapies such as infliximab (IFX) and cyclosporine A (CsA). IFX (anti-TNFα) and CsA (calcineurin inhibitor) are guideline-endorsed options for Steroid Refractory Acute Severe Ulcerative Colitis (SR-ASUC), yet comparative efficacy and safety remain uncertain. Methods: A meta-analysis was conducted to evaluate the efficacy and safety of IFX vs CsA in SR-ASUC. A literature search was performed across PubMed, Embase, Cochrane CENTRAL, and clinicaltrial.gov through April 2025. Dual reviewers screened and extracted data. Random-effects models generated pooled odds ratios (OR) with 95% confidence intervals (CI); heterogeneity was quantified with I². Primary outcomes were treatment response and need for colectomy at 3 and 12 months. Secondary outcomes included adverse drug reactions (ADR), postoperative complications, and mortality. Results: Twenty-one studies with a total of 2225 participants were included. CsA had significantly higher short-term treatment response (OR = 2.11, 95% CI 1.43-3.12; P = 0.0002; I² = 48%). In contrast, IFX was associated with a significantly lower need for colectomy at 3 months (OR = 0.59, 95% CI 0.39-0.91; P = 0.02; I² = 52%) and at 12 months (OR = 0.52, 95% CI 0.36–0.76; P = 0.0007; I² = 61%). No significant difference in overall adenoma detection rate (OR = 1.18, 95% CI 0.77–1.83), postoperative complication (OR = 1.08, 95% CI 0.49–2.37), and mortality (OR = 0.97, 95% CI 0.36–2.64) was noted. Conclusion: SR-ASUC is a life-threatening condition requiring hospitalization and surgery. Discrepancies were noted in previous studies on the use of IFX and CsA. Narula et al. found a lower risk of colectomy at 12 months in the IFX group. Ordas et al. reported fewer ADRs with CsA. Another crucial point was the healthcare cost. While CsA requires continuous IV administration with constant monitoring of levels, IFX requires a shorter hospital stay. Our findings suggest that although CsA offers better treatment response, IFX is associated with lower colectomy rates. No significant difference in secondary outcome was seen. Further large randomized controlled trials assessing the quality of life, cost-effectiveness, and treatment predictors will help guide the safest, most colon-saving rescue plan.