Real-world experience and effectiveness of an accelerated step-up therapy in children with IBD

Objectives:
To evaluate the real-world effectiveness of an accelerated step-up regimen in pediatric inflammatory bowel disease (PIBD), to identify clinical predictors of primary steroid non-response and arl relapse on Azathioprine maintenance.

Methods:
We conducted a single-center prospective observational study at a tertiary pediatric gastroenterology unit (2018–2025). Forty children (28 Crohn’s disease, 12 ulcerative colitis) were included. Baseline demographic, clinical, laboratory, endoscopic, and histological parameters were collected. Steroid response was assessed using PUCAI/PCDAI scores at 10 weeks. Logistic regression identified predictors of non-response and relapse on azathioprine maintenance.

Results:
Steroid response was achieved in 87.5% (35/40), while 12.5% (5/40) were non-responders requiring biologics. Non-response was significantly associated with poor nutritional status (weight-for-age and weight-for-height <3rd centile, p<0.05) and shorter symptom duration (<4 months at diagnosis, p=0.03). Among responders, 23% relapsed within one year on azathioprine maintenance. Pancolitis in ulcerative colitis and higher endoscopic severity in Crohn’s disease trended toward higher relapse, though not statistically significant.

Conclusions:
The accelerated step-up regimen was effective for most children with PIBD, reserving biologics for a minority with early non-response. Malnutrition and shorter symptom duration at diagnosis predicted steroid non-response, underscoring the need for risk stratification at presentation. Compared with top-down biologic-first approaches, this pragmatic step-up strategy offers balance in TB-endemic, resource-limited settings, though long-term de-escalation remains a challenge.

To be updated shortly..