Navigating Treatment Selection in Acute Severe Ulcerative Colitis: A Prospective Mixed Method Analysis of Factors Influencing Patient Decision-Making

PURPOSE: Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency necessitating immediate hospitalization and rapid initiation of therapy. For decades, intravenous (IV) corticosteroids have remained first-line, with rescue therapies reserved for patients who are corticosteroid-refractory. However, the therapeutic landscape has evolved, shifting toward earlier initiation of advanced therapy. This study analyzes factors influencing patient decision-making for treatment of ASUC. METHODS: In this prospective, mixed-methods study, patients with ASUC who were infliximab and Janus kinase inhibitor naïve were enrolled. Participants were presented with educational resources on IV corticosteroids, upadacitinib, and infliximab and then asked to choose between continuing IV corticosteroids alone or starting early initiation of advanced therapy in addition to IV corticosteroids. Factors influencing their preferences were captured via semi-structured interviews, and clinical outcomes were followed. RESULTS: Eleven patients were prospectively enrolled. Analysis of semi-structured interviews revealed five dominant themes influencing treatment decision-making: (1) reliance on physician expertise, (2) contextualized treatment selection, (3) concrete risk assessment, (4) empathetic individualization, and (5) strong preference for oral therapy. Notably, we observed significant discordance between patient treatment preferences and medication initiated following discussion between the participant and their primary clinical team, particularly among participants favoring upadacitinib. CONCLUSION: These five principal themes offer actionable opportunities to assist patients in making well-informed decisions regarding ASUC therapy. Clinicians should utilize these insights to develop evidence-based patient decision aids that specifically address patient priorities. While patients often prioritize oral therapy, their choices often diverge from the therapy initiated after discussing with their primary clinical team. Future efforts should focus on bridging this discordance by integrating patient priorities with available evidence into the clinical decision-making process.