In patients with moderately active UC not responding to mesalamine, is prednisone induction or azathioprine preferred

What is known

- BSG guidelines recommend oral prednisolone when 5-ASA induction fails or is not tolerated, graded as strong recommendation, high-quality evidence. ¹ - Systemic glucocorticoids induce remission with a number needed to treat of about three; response is expected within about two weeks, then tapered. ² - Corticosteroids should not be used for maintenance owing to lack of long-term efficacy and side effects; azathioprine/mercaptopurine are indicated for frequent or severe relapses or steroid dependence. ^2,3

What is unknown / caveats

- Topically-acting oral corticosteroids (e.g., budesonide-MMX) are noted as alternatives for those avoiding systemic steroids ^1,4 - Excerpts frame azathioprine as maintenance/steroid-sparing, not as an induction agent, and do not provide a head-to-head induction comparison - The excerpts do not report azathioprine efficacy or onset for inducing remission in this setting.

## References

1. Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019;68(Suppl 3):s1-s106. PMID: 31562236.

2. Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet. 2017;389:1756-1770. PMID: 27914657.

3. Rammert C, Kullak-Ublick GA. [Management of ulcerative colitis]. Ther Umsch. 2003;60:145-50. PMID: 12693317.

4. Kucharzik T, Koletzko S, Kannengiesser K, Dignass A. Ulcerative Colitis-Diagnostic and Therapeutic Algorithms. Dtsch Arztebl Int. 2020;117:564-574. PMID: 33148393.

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_Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._