Letter: Steroid Tapering in Ulcerative Colitis—The Importance of Disease Severity and Maintenance Therapy. Authors' Reply

We thank O'Connor et al. for their insightful comments on our randomised trial [1, 2]. We agree that the paradigm in the developed world is fast shifting to early initiation of effective (read advanced) therapies to achieve durable remission and better outcomes. While we agree that advanced therapies are effective, so are steroids. However, the use of steroids is often frowned upon by most modern IBDologists primarily for two reasons: lack of maintenance role of steroids and the rather slow onset of action of the de facto maintenance in steroid-induced remission, that is thiopurines [3]. Our RCT proves the same—a longer taper allowed thiopurines to take effect, while a short taper did not. The results of our RCT may therefore be related to the choice of maintenance therapy. Arguably, the use of a different (and rapid acting) maintenance therapy would help reduce steroid exposure, as suggested by the ACTIVE trial [3, 4]. The availability of cheaper generic versions of JAK inhibitors, including tofacitinib and upadacitinib, in India will likely shift the paradigm towards shorter steroid use in India. One hopes that this becomes the norm in regions where access to modern advanced therapy still remains a pipe dream [5]. We agree that steroid-related adverse events may remain undetected using telephonic consults and in the absence of laboratory investigations. It is certainly not our argument to be a proponent for steroid overuse. The steroids are sometimes ‘a necessary evil’, and it is important to ensure appropriate steroid use in all settings and regions. It is also important to improve access to advanced therapies and training in the use of these newer agents in the developing world; otherwise, steroids will remain the de facto induction agent for every relapse and may continue to be used as maintenance therapy [7]. Ankit Kumar: conceptualization, writing – review and editing. Amol N. Patil: conceptualization, writing – review and editing. Vishal Sharma: conceptualization, writing – review and editing, writing – original draft. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. 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.70642. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.