In adolescents newly diagnosed with extensive UC, are systemic corticosteroids or immediate biologic therapy preferred

What is known

- In the PROTECT inception cohort, children newly diagnosed with UC received standardized mesalamine or oral/intravenous corticosteroids by severity, escalating to immunomodulators or infliximab per predetermined criteria. ¹ - Need for biologic therapy and colectomy by 12 weeks was largely confined to patients presenting with more severe disease. ² - Early biologic use is recommended for acute severe UC admitted to hospital and for steroid-refractory disease; corticosteroids remain first-line for ASUC per consensus guidelines. ^3,4 - Poor prognostic factors, young onset age, extensive colitis, deep ulcerations, or steroid dependence, identify patients who should step up to thiopurines or biologics. ³

What is unknown / caveats

- Excerpts describe step-up protocols and predictors, not a head-to-head trial of immediate biologic versus corticosteroid induction at diagnosis - Steroid resistance is common in pediatric UC (reported ~46%), which the step-up algorithms accommodate through escalation rather than upfront biologics - The retrieved evidence does not directly compare immediate biologic initiation against standard corticosteroid/mesalamine induction in newly diagnosed extensive pediatric UC.

## References

1. Hyams JS, Brimacombe M, Haberman Y, Walters T, Gibson G, Mo A, Mack D, Griffiths A, Boyle B, LeLeiko N, Markowitz J, Rosh J, Patel A, Shah S, Baldassano R, Pfefferkorn M, Sauer C, Dailey J, Venkateswaran S, Kugathasan S, Denson LA. Clinical and Host Biological Factors Predict Colectomy Risk in Children Newly Diagnosed With Ulcerative Colitis. Inflamm Bowel Dis. 2022;28:151-160. PMID: 33904583.

2. Hyams JS, Davis S, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz J, Baker SS, Rosh J, Baldassano RN, Patel A, Pfefferkorn M, Otley A, Heyman M, Noe J, Oliva-Hemker M, Rufo P, Strople J, Ziring D, Guthery SL, Sudel B, Benkov K, Wali P, Moulton D, Evans J, Kappelman MD, Marquis A, Sylvester FA, Collins MH, Venkateswaran S, Dubinsky M, Tangpricha V, Spada KL, Britt A, Saul B, Gotman N, Wang J, Serrano J, Kugathasan S, Walters T, Denson LA. Factors associated with early outcomes following standardised therapy in children with ulcerative colitis (PROTECT): a multicentre inception cohort study. Lancet Gastroenterol Hepatol. 2017;2:855-868. PMID: 28939374.

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

4. Kato M, Yamashita M, Tsukui M, Iijima Y, Araki K, Shikano N, Saji S, Tsukamoto K, Ishida J, Komatsu T, Nakamoto Y, Kawashima A, Endo A, Matsunaga A, Sato Y, Maehata T, Tateishi K. An Adolescent Case of Ulcerative Colitis Complicated by Toxic Megacolon. Case Rep Gastroenterol. 2025. PMID: 41323444.

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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._