LAUSR

A 27-year-old female with a history of hypertension was diagnosed with pan-ulcerative colitis (UC) after experiencing several weeks of diarrhea, hematochezia, and abdominal cramping. She was initially treated with 5-ASA and azathioprine, both of which did not control her symptoms. She was started on infliximab at 5 mg/kg every 8 weeks but had persistent moderate proctitis as assessed by colonoscopy after several months of therapy. Her dose was gradually increased to 7.5 mg/kg, and then, 10 mg/kg every 6 weeks after follow-up colonoscopy demonstrated moderate erythema and friability from the ascending colon to the cecum. A repeat colonoscopy after 6 months at this dose revealed ongoing moderate inflammation in the cecum. At this time, her serum laboratory markers were normal including C-reactive protein (1.1 mg/L), sedimentation rate (17 mm/h), albumin (4.3 g/ dL), and platelet count (245 K/μL). Since her infliximab levels were therapeutic and infliximab antibodies were not present, she was transitioned three months later to vedolizumab 300 mg every 8 weeks without a trial of methotrexate due to patient preference. Though she initially reported symptomatic improvement after 3 months of vedolizumab therapy, she endorsed abdominal cramping and loose stools at week 7 of every treatment cycle. Her dose interval was decreased to every 6 weeks, and she was started on oral budesonide. She was able to wean off of budesonide but again became mildly symptomatic with intermittent cramping and blood in her stools over the subsequent 4 months. Since her fecal calprotectin was 1084 μg/mg, she was started on azathioprine (1.5 mg/kg) accompanied by a dose interval decrease in vedolizumab to every 4 weeks. After 3 months, a colonoscopy showed mild proctitis as well as moderate inflammation from the hepatic flexure to the cecum. She was evaluated for total proctocolectomy; however, she preferred to pursue medical therapy. She subsequently completed a 6-week trial of a partial elemental diet which improved clinical symptoms with 1 formed stool daily and improvement in fecal calprotectin to 122 μg/mg. Nonetheless, after resumption of a regular diet, her symptoms were again uncontrolled with loose stools and crampy abdominal discomfort. Repeat colonoscopy showed ongoing moderate colitis from the hepatic flexure to the ascending colon. Pathology revealed moderately active chronic colitis in the right colon. The terminal ileum was endoscopically and microscopically normal. She again expressed interest in maximizing medical therapy, and ustekinumab and tofacitinib therapies were both discussed. Due to her predominantly right-sided colonic inflammation, her UC phenotype was felt to be similar to that of Crohn’s disease; she was therefore started on, at the time, off-label ustekinumab therapy. She was started on a standard weight-based infusion followed by subcutaneous A profile of Rahul S. Dalal is available at https ://doi.org/10.1007/ s1062 0-021-06853 -2.