Advances in the clinical management of acute severe ulcerative colitis

Acute severe ulcerative colitis (ASUC) is a critical emergency life-threatening complication of inflammatory bowel disease. A subset of patients fails to respond to first-line intravenous corticosteroid therapy and requires timely salvage treatment. Previously, guidelines recommended infliximab and cyclosporine as the main salvage therapies; however, recent years have witnessed clinical advances. Accelerated and intensified dosing regimens of infliximab, compared with standard dosing, may help patients with high inflammatory burden and hypoalbuminemia achieve earlier clinical and biochemical remission. Among small molecule Janus kinase inhibitors, tofacitinib as an adjunct to intravenous corticosteroids has been shown to improve short-term clinical response rates, while upadacitinib has shown promising efficacy as a salvage therapy when intravenous corticosteroids, standard or intensified infliximab are ineffective. For patients unresponsive to monotherapy or those with extraintestinal manifestations, dual-targeted therapy, through multi-pathway synergistic blockade, achieves superior clinical, endoscopic, and biochemical outcomes compared to monotherapy, providing new evidence-based support for treatment optimization. In addition, exclusive enteral nutrition and hyperbaric oxygen therapy play important roles in the comprehensive management of ASUC by modulating the gut microbiota and promoting mucosal healing, respectively. This review summarizes the therapeutic outcomes and limitations of these emerging pharmacological agents or regimens in the clinical treatment of ASUC, aiming to provide a reference for optimizing clinical management strategies for ASUC.