We read with great interest the study done by Kumar et al. which showed that a shorter taper duration of 6 weeks was inferior to a longer taper of 10 weeks in achieving clinical remission in moderate to severe ulcerative colitis at 6 months 1. We congratulate the authors on this study, as no guidelines have clearly mentioned the strategy for steroid tapering in moderate to severe ulcerative colitis. We would like to add a few comments on the conclusion of the study and a few inputs to approach the strategy of tapering steroid dose. We really appreciate the team for this good, randomised trial which not only studied the clinical, endoscopic response but also investigated the histopathology and gut microbiome in these patients. In this study, the baseline duration of disease in both groups and previous steroid exposure is not clear. Both will have an impact on remission, relapse rate, and will have an impact on starting immunomodulator. At baseline, the proportion of patients (16% vs. 19%) were on Azathioprine/6-MP; however, its dosage, duration, and whether they continued the same dose or optimization of dose or change to another maintenance regimen was done is not clear. In this study long and short term (10 vs. 6 weeks) were used, compared to previous studies ( 6 weeks) 2. Previous study clearly favouring short course saying similar efficacy with reduced side effects. Majority guidelines recommend tapering steroids in 6–8 weeks, however in clinical practice patient centric approach in tapering steroid is more practical 3. At 6 months follow up, only a small proportion of patients in steroid-free clinical remission (44% vs. 20%). Why did these patients not switch to another mode of treatment? Also, 6 months follow up is too short to assess the risk of relapse and maintenance of remission. Authors concluded that this has implications for the Low-Middle-income country, where the majority will be on thiopurine as maintenance therapy as the majority cannot afford biological therapy. This is not true with the availability of small molecules (tofacitinib, upadacitinib), which have now changed management of IBD (both induction and maintenance) and are affordable to the majority in these countries 4, 5. To conclude, we totally agree with the author that a short course of steroid (6 weeks) is not appropriate and inferior; however, we suggest that rather than fixing the duration as 10 weeks, a patient-centric approach depending on the response should be used to taper the dose of steroid. Ganesh Bhat: writing – review and editing, conceptualization. Athish Shetty: writing – review and editing. The authors have nothing to report. This article is linked to Kumar et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70509 and https://doi.org/10.1111/apt.70552. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Bhat et al. (Wed,) studied this question.