Management of Steroid-Refractory Immune Checkpoint Inhibitor Colitis: A Practical Guide to Advanced Therapies

Résumé

Key Takeaways
When to escalate: Patients with steroid-refractory or steroid-dependent immune checkpoint inhibitor colitis should receive advanced immunosuppressive therapy. Earlier escalation should be considered when endoscopy demonstrates high-risk features, particularly deep ulcerations, which predict steroid failure.

Which agent to choose: Infliximab and vedolizumab are the preferred advanced therapies and have comparable efficacy. Agent selection should be individualized based on the clinical context: infliximab is generally preferred for acute, severe disease requiring rapid control, whereas the gut-selective mechanism of vedolizumab may be favoured when immune checkpoint inhibitor rechallenge is anticipated.

How long to treat: At least three induction doses are recommended; however, treatment duration should be guided by objective markers of disease activity, such as fecal calprotectin levels and endoscopic mucosal healing, rather than by the number of doses alone. The intent to resume checkpoint-inhibitor therapy does not dictate the number of induction infusions but may support adding maintenance biologic therapy at the time of rechallenge to reduce recurrence risk.