Long-term comparative effectiveness of first-line infliximab vs corticosteroids in ulcerative colitis: Remission and colectomy risk

Abstract

BACKGROUNDIntravenous corticosteroids (IVCS) are the conventional first-line therapy for moderate-to-severe ulcerative colitis (UC), but are often limited by nonresponse, steroid dependence, and relapse.Infliximab (IFX) is an alternative first-line option; however, long-term comparative data between IFX and IVCS remain limited. AIMTo compare the long-term durability of disease remission and surgical outcomes associated with first-line IFX vs IVCS in patients with moderate-to-severe UC. METHODSIn this multicenter prospective cohort study, adult patients (≥ 18 years) with moderate-to-severe UC were enrolled between September 2019 and September 2025 from three tertiary care hospitals in Jeddah, Saudi Arabia.Disease severity was assessed using the Mayo score and Geboes histologic grading.Patients received either first-line IFX (5 mg/kg at weeks 0, 2, and 6, followed by 8-weekly maintenance) or first-line IVCS (methylprednisolone 40-60 mg/day or hydrocortisone 300-400 mg/day).Participants were followed for at least 24 months, with clinical, biochemical, endoscopic, and histologic assessments performed at predefined intervals up to 144 weeks.Colectomy was considered for patients with nonresponse or loss of remission despite medical therapy. RESULTSOf 152 enrolled patients, 139 completed follow-ups (68 IFX, 71 IVCS).At weeks 12, clinical response rates were significantly higher with IFX than IVCS (77.9% vs 56.3%, P = 0.007), and this benefit was sustained throughout follow-up.By weeks 144, IFXtreated patients demonstrated significantly higher rates of clinical remission (36.8% vs 15.5%, P = 0.006), endoscopic remission (25.0%vs 9.9%, P = 0.006), and histologic remission (20.6% vs 7.0%, P = 0.026).Adverse events were comparable overall.Cumulative incidence of colectomy was significantly lower in the IFX group than in 4 / 34 the IVCS group (5.9% vs 18.3%, P = 0.037).In adjusted analyses, IFX treatment was independently associated with a lower hazard of colectomy compared with IVCS (hazard ratio = 0.53, 95%CI: 0.20-0.88;P = 0.043). CONCLUSIONIn this real-world tertiary-care cohort, IFX was associated with superior and sustained remission and with a significantly reduced long-term colectomy risk compared with IVCS in moderate-to-severe UC, supporting consideration of early biologic therapy in selected high-risk patients.