Optimizing Immunosuppressive Treatment for UC Patients with CMV Colitis: A Multicenter Real-world Study

Background : Ulcerative colitis (UC) patients with concomitant cytomegalovirus (CMV) colitis face higher disease activity and poorer prognosis. While antiviral therapy improves outcomes, optimal immunosuppressive management during treatment remains controversial, particularly regarding steroid use. Methods : In this two-center retrospective study, hospitalized patients with moderate-to-severe UC with concomitant CMV colitis from April, 2013 to February, 2024 were stratified into intensified and attenuated treatment groups. Primary outcome was colectomy on Week 26 since the diagnosis of CMV colitis. Secondary outcome included clinical response and remission on the 7th and 14th day, and colectomy on Week 52. A subgroup analysis based on the virus load was performed. Results : The cumulative dose of baseline steroids in the attenuated treatment group was higher than that in the intensified treatment group (1.5±1.9g vs 0.7±1.2g, P=0.008). After adjusting for cumulative steroid dose, intensified therapy reduced colectomy risk at 26 weeks (OR=0.223, 95%CI=0.098–0.510, P<0.001) and 52 weeks (OR=0.299, 95%CI=0.141–0.635, P=0.002), while attenuated therapy significantly improved day 7 clinical remission rates (OR=0.360, 95%CI=0.161–0.805, P=0.013). In the subgroup analysis, in the high-grade CMV colitis subgroup, different treatments had no significant difference in outcomes; in the low-grade CMV colitis subgroup, attenuated treatment enhanced day 7 and 14 clinical remission rates, and intensified treatment reduced colectomy risks at 26 and 52 weeks. Conclusion : Immunosuppressive strategies in UC with CMV colitis require dynamic, stage-specific adjustments. Short-term attenuation may enhance antiviral response, whereas long-term intensification reduces colectomy risk. Individualized therapy balancing immediate and long-term outcomes is critical.