101
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Jiang XG, Sun K, Liu YY, Yan L, Wang MX, Fan JY, Mu HN, Li C, Chen YY, Wang CS, Han JY. Astragaloside IV ameliorates 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis implicating regulation of energy metabolism. Sci Rep 2017; 7:41832. [PMID: 28150820 PMCID: PMC5288804 DOI: 10.1038/srep41832] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/28/2016] [Indexed: 02/07/2023] Open
Abstract
Dysfunction of energy metabolism is involved in inflammatory bowel disease (IBD). This study was designed to investigate the potential of astragaloside IV (ASIV), an active ingredient of Radix Astragalus, to ameliorate colonic mucosal injury, with focusing on the implication of energy restoration in the underlying mechanism. Experimental colitis model was established in rats by injecting 2,4,6-trinitrobenzene sulfonic acid (TNBS) through anus. After 24 hours, ASIV was administrated once daily by gavage for 6 days. On day 1 and day 7, colon tissue was collected for macroscopic and histological examination, ELISA, Western blot and immunohistochemical analysis. TNBS impaired colonic mucosa with an injured epithelial architecture, increased inflammatory cell infiltration, and decreased colonic blood flow. Lgr5 positive cell number in crypt and β-catenin nuclear translocation were down-regulated by TNBS treatment. TNBS induced epithelial F-actin disruption and junctional protein degradation. Furthermore, adenosine triphosphate (ATP) content and ATP synthase subunit β expression in the colon tissue were significantly decreased after TNBS stimulation. All of the aforementioned alterations were relieved by ASIV post-treatment. The present study revealed that ASIV promoted mucosal healing process in TNBS-induced colitis, which was most likely attributed to regulating energy metabolism.
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Affiliation(s)
- Xu-Guang Jiang
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Shandong college of Traditional Chinese Medicine, Yantai, Shandong, China
| | - Kai Sun
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Department of Integration of Chinese and Western Medicine, School of Basic Medical Sciences, Peking University, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Yu-Ying Liu
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Li Yan
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Ming-Xia Wang
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Jing-Yu Fan
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Hong-Na Mu
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Chong Li
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Yuan-Yuan Chen
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Chuan-She Wang
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Department of Integration of Chinese and Western Medicine, School of Basic Medical Sciences, Peking University, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
| | - Jing-Yan Han
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China.,Department of Integration of Chinese and Western Medicine, School of Basic Medical Sciences, Peking University, Beijing, China.,Key Laboratory of Microcirculation, State Administration of Traditional Chinese Medicine, Beijing 100191, China.,Key Laboratory of Stasis and Phlegm of State Administration of Traditional Chinese Medicine, Beijing 100191, China
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102
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McCann RK, Smith K, Gaya DR. A prospective single centre pilot evaluation of a serum calprotectin assay in unselected GI patients. Clin Biochem 2017; 50:533-536. [PMID: 28093196 PMCID: PMC5480541 DOI: 10.1016/j.clinbiochem.2017.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/15/2016] [Accepted: 01/10/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Whilst C-reactive protein (CRP) is an established serum marker of inflammation, its use in gastroenterology has been limited by its poor sensitivity and specificity for GI disease. Faecal calprotectin (FC) has been adopted into mainstream GI practice as a sensitive but non-specific marker of intestinal inflammation. However, stool samples collection for FC can be challenging and the possibility of utilising a sensitive and specific serum biomarker of intestinal inflammation in luminal gastroenterology is an attractive prospect. This work investigates the performance of serum calprotectin (SC) compared to current biomarkers, FC and CRP, in an unselected cohort of patients attending our GI unit. METHODS Patients attending in and outpatients within an adult GI service who submitted a stool sample for FC analysis were identified. A total of 109 who had a serum sample obtained within one day of stool sample collection had the serum analysed for CRP and SC and the correlation between these biomarkers was investigated. RESULTS The intraclass correlation coefficient (ICC) between SC, FC and CRP was 0.10, 95% CI -0.09-0.28 and 0.18, 95% CI -0.01-0.35, respectively. The ICC between FC and CRP was 0.18, 95% CI -0.01-0.35. CONCLUSIONS Our data reveals that there is no significant correlation between SC and FC, nor between SC and CRP in a large unselected cohort of GI patients. Therefore, as a serum biomarker for intestinal inflammation, SC is unlikely to be of clinical utility and the search for an appropriate serum GI biomarker continues.
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Affiliation(s)
- Rebecca K McCann
- Department of Clinical Biochemistry, Glasgow Royal Infirmary, Glasgow, UK
| | - Karen Smith
- Department of Clinical Biochemistry, Glasgow Royal Infirmary, Glasgow, UK
| | - Daniel R Gaya
- Gastroenterology Unit, Glasgow Royal Infirmary, Glasgow, UK.
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103
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Naganuma M, Yahagi N, Bessho R, Ohno K, Arai M, Mutaguchi M, Mizuno S, Fujimoto A, Uraoka T, Shimoda M, Hosoe N, Ogata H, Kanai T. Evaluation of the severity of ulcerative colitis using endoscopic dual red imaging targeting deep vessels. Endosc Int Open 2017; 5:E76-E82. [PMID: 28180151 PMCID: PMC5283170 DOI: 10.1055/s-0042-119393] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background and study aims Colonoscopies can predict long-term prognoses in patients with ulcerative colitis (UC). Recently, a new imaging technology has been developed that uses 3 types of illumination with center wavelengths of 540 nm, 600 nm, and 630 nm. The use of both the 600-nm and 630-nm lights (Dual red imaging; DRI) is critical for identifying blood vessels in deeper tissue. The aim of this study was to evaluate the usefulness of DRI for assessing the severity of inflammation in patients with UC. Patients and methods A total of 43 UC patients were retrospectively enrolled to evaluate the endoscopic severity of 112 colon segments, and Mayo endoscopic scores, DRI scores and the severity of inflammation on a visual analogue scale (VAS) were compared. The Mayo endoscopic scores, DRI scores, and histologic scores were evaluated, and the interobserver agreement on DRI scores among 5 investigators was also assessed. The usefulness of DRI scores for predicting prognoses was also assessed in patients with clinical remission. Results The DRI scores were closely correlated with the VAS for the severity of colonic inflammation (r = 0.96) and the histologic scores (r = 0.72 - 0.8). The DRI scores had a higher rate of interobserver agreement (κ values = 0.63 - 0.88) than the Mayo endoscopic scores (κ values = 0.44 - 0.59). Inter-observer agreement between 4 non-experts was also excellent (mean κ value = 0.76, range 0.63 - 0.82). The expected time until recurrence was significantly longer in patients with lower DRI scores (P < 0.01). Conclusion DRI can be used in patients with mild to moderate endoscopic severity because it targets the deep vascular pattern. The prognosis of UC can be predicted by assessing deep vessels using DRI.
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Affiliation(s)
- Makoto Naganuma
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan,Center for Diagnostic and Therapeutic Endoscopy, Keio University, Tokyo, Japan,Corresponding author Makoto Naganuma, MD, PhD Division of Gastroenterology and HepatologySchool of Medicine, Keio University35 Shinanomachi, Shinjuku-kuTokyo, 160-8582, Japan+81-3-3341-3631
| | | | - Rieko Bessho
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan
| | - Keiko Ohno
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan
| | - Mari Arai
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan
| | - Makoto Mutaguchi
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan
| | - Shinta Mizuno
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan
| | - Ai Fujimoto
- Cancer Center, Keio University, Tokyo, Japan
| | | | | | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University, Tokyo, Japan
| | | | - Takanori Kanai
- Department of Gastroenterology and Hepatology, Keio University, Tokyo, Japan
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104
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Ryu DG, Kim HW, Park SB, Kang DH, Choi CW, Kim SJ, Nam HS. Assessment of disease activity by fecal immunochemical test in ulcerative colitis. World J Gastroenterol 2016; 22:10617-10624. [PMID: 28082814 PMCID: PMC5192273 DOI: 10.3748/wjg.v22.i48.10617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/15/2016] [Accepted: 11/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the efficacy of quantitative fecal immunochemical test (FIT) as biomarker of disease activity in ulcerative colitis (UC).
METHODS Between February 2013 and November 2014, a total of 82 FIT results, obtained in conjunction with colonoscopies, were retrospectivelyevaluated for 63 patients with UC. The efficacy of FIT for evaluation of disease activity was compared to colonoscopic findings. Quantitative fecal blood with automated equipment examined from collected feces. Endoscopic disease severity were assessed using the Mayo endoscopic subscore (MES) classification. The extent of disease were classified by proctitis (E1), left sided colitis (E2), and extensive colitis (E3). Clinical activity were subgrouped by remission or active.
RESULTS All of 21 patients with MES 0 had negative FIT (< 7 ng/mL), but 22 patients with MES 2 or 3 had a mean FIT of > 134.89 ng/mL. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of negative FIT about mucosal healing were 73.33%, 81.82%, 91.49%, 51.43% and 73.17%, respectively. The sensitivity, specificity, PPV, NPV and accuracy of predictive value of positive FIT (cutoff value > 100 ng/mL) about active disease status were 45.45%, 93.33%, 71.43%, 82.35% and 26.83%, respectively. Among patients with clinical remission, FIT was negative in 31 (81.6%) of 38 cases, with a mean fecal hemoglobin concentration of 6.12 ng/mL (range, negative to 80.9 ng/mL) for this group of patients. Among patients with clinical active disease, FIT was negative in 16 (36.4%) out of 44 cases, with a mean fecal hemoglobin concentration > 167.4 ng/mL for this group of patients. FIT was positively correlated with endoscopic activity (r = 0.626, P < 0.01) and clinical activity (r = 0.496, P < 0.01). But, FIT did not correlate with the extent of disease (r = -0.047, P = 0.676)
CONCLUSION Quantitative FIT can be a non-invasive and effective biomarker for evaluation of clinical and endoscopic activity in UC, but not predict the extent of disease.
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105
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Arai M, Naganuma M, Sugimoto S, Kiyohara H, Ono K, Mori K, Saigusa K, Nanki K, Mutaguchi M, Mizuno S, Bessho R, Nakazato Y, Hosoe N, Matsuoka K, Inoue N, Ogata H, Iwao Y, Kanai T. The Ulcerative Colitis Endoscopic Index of Severity is Useful to Predict Medium- to Long-Term Prognosis in Ulcerative Colitis Patients with Clinical Remission. J Crohns Colitis 2016; 10:1303-1309. [PMID: 27194529 DOI: 10.1093/ecco-jcc/jjw104] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/25/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The ulcerative colitis endoscopic index of severity [UCEIS] is a validated scoring system. Nevertheless, few studies have investigated its usefulness in clinical settings. In this study, we aimed to predict the clinical prognosis of patients with ulcerative colitis [UC] in clinical remission using the UCEIS. METHODS A total of 285 UC patients who underwent a colonoscopy between April 2012 and March 2013 were enrolled. We reviewed clinical characteristics and endoscopic scores at the time of the colonoscopy and checked the clinical remission rate of the patients until September 2015. Clinical remission and recurrence were defined as a partial Mayo score of ≤1 and ≥3, respectively. RESULTS UCEIS was strongly correlated with the Mayo endoscopic score [r=0.93], moderately correlated with clinical severity [r=0.64] and mildly correlated with C-reactive protein [r=0.34]. The recurrence rate increased gradually as it became more endoscopically severe [5.0% for UCEIS=0, 22.4% for UCEIS=1, 27.0% for UCEIS=2, 35.7% for UCEIS=3 and 75.0% for UCEIS=4-5] in patients with clinical remission. UCEIS and the concomitant use of thiopurine were independent factors predicting clinical recurrence. A multivariate analysis indicated that the absence of bleeding [p≤0.001] and the absence of mucosal damage [p<0.001] in a colonoscopy were independent factors for prolongation of clinical remission. CONCLUSION The UCEIS is useful to predict the medium- to long-term outcomes of UC patients with clinical remission. The absence of bleeding or mucosal damage is important for maintaining clinical remission.
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Affiliation(s)
- Mari Arai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Sugimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Kiyohara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keiko Ono
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyoto Mori
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keiichiro Saigusa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kosaku Nanki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Mutaguchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinta Mizuno
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Bessho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshihiro Nakazato
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Nagamu Inoue
- Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Iwao
- Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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106
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Male-specific association between MT-ND4 11719 A/G polymorphism and ulcerative colitis: a mitochondria-wide genetic association study. BMC Gastroenterol 2016; 16:118. [PMID: 27716073 PMCID: PMC5048482 DOI: 10.1186/s12876-016-0509-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022] Open
Abstract
Background Ulcerative colitis (UC) is a chronic inflammatory disorder of still unknown pathogenesis. Increasing evidence indicates that alterations in mitochondrial respiration and thus adenosine triphosphate (ATP) production are involved. This may contribute to mucosal energy deficiency and subsequently intestinal barrier malfunction, which is accepted to be a major hallmark of UC. Genetic alterations of the mitochondrial genome are one cause of mitochondrial dysfunction. However, less is known about mitochondrial gene polymorphisms in UC. Therefore, we aimed at identifying genetic associations between mitochondrial polymorphisms and UC. Methods German UC cases (n = 1062) and German healthy controls (n = 3030) were genotyped using the Affymetrix Genome-Wide Human SNP Array 6.0. The primary association analysis was to test for associations between mitochondrial single nucleotide polymorphisms (SNPs) and UC using Fisher’s exact test in the total sample and stratified by sex. In addition, we tested for associations between mitochondrial haplogroups and UC and for interactions between the most promising mitochondrial SNPs and nuclear SNPs. An independent set of German subjects with 1625 UC cases and 3575 controls was used for replication. Results We identified a genetic association between the MT-ND4 11719 A/G polymorphism and UC in the subgroup of males (rs2853495; odds ratio, 1.40; 95 % confidence interval, 1.13 to 1.73; p = 0.002). This association was replicated in the second independent cohort. In the association analysis based on mitochondrial haplogroups the lowest p values were reached for haplogroups HV and T (p = 0.029 and 0.035). Haplogroup HV is determined by the mitochondrial 11719 A/G polymorphism. Accordingly, this association was only found in the subgroup of males (p = 0.009). Conclusions For the first time, we observed an association between the MT-ND4 11719 A/G polymorphism and UC. The gene MT-ND4 encodes for a subunit of the mitochondrial electron transport chain complex I, which is pivotal for ATP production and might therefore contribute to mucosal energy deficiency. The male-specific association indicates differences between males and females concerning the impact of mitochondrial gene polymorphisms on the development of UC. Further investigations of the functional mechanism underlying this association and the relevance of the gender-specificity are highly warranted. Electronic supplementary material The online version of this article (doi:10.1186/s12876-016-0509-1) contains supplementary material, which is available to authorized users.
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107
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Patil DT, Moss AC, Odze RD. Role of Histologic Inflammation in the Natural History of Ulcerative Colitis. Gastrointest Endosc Clin N Am 2016; 26:629-40. [PMID: 27633592 DOI: 10.1016/j.giec.2016.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The goals of therapy for ulcerative colitis have moved from symptom improvement to mucosal healing, and finally histologic resolution. The natural history of histologic inflammation in ulcerative colitis progresses from initial cellular infiltration to architectural disruption and recovery on medical therapy. Many studies have linked histologic changes to clinical outcomes, providing prognostic value to histologic abnormalities. This review covers all these components.
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Affiliation(s)
- Deepa T Patil
- Cleveland Clinic, 9500 Euclid Av, L-25, Cleveland, OH 44195, USA.
| | - Alan C Moss
- Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA
| | - Robert D Odze
- Gastrointestinal Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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108
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Shah SC, Colombel JF, Sands BE, Narula N. Mucosal Healing Is Associated With Improved Long-term Outcomes of Patients With Ulcerative Colitis: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:1245-1255.e8. [PMID: 26829025 DOI: 10.1016/j.cgh.2016.01.015] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/20/2016] [Accepted: 01/24/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The paradigm for treatment for ulcerative colitis (UC) is shifting from resolving symptoms toward objective measures such as mucosal healing (MH). However, it is unclear whether MH is associated with improved long-term outcomes. We performed a systematic review and meta-analysis to identify and analyze studies comparing long-term outcomes of patients with MH with those without MH. METHODS We performed a systematic search of 3 large databases to identify prospective studies of patients with active UC that included outcomes of patients found to have MH at the first endoscopic evaluation after initiation of UC therapy (MH1) compared with those without MH1. The primary outcome was clinical remission after at least 52 weeks. Secondary outcomes included proportions of patients who were free of colectomy or corticosteroids and rate of MH after at least 52 weeks. RESULTS We analyzed 13 studies comprising 2073 patients with active UC. Patients with MH1 had pooled odds ratio of 4.50 for achieving long-term (after at least 52 weeks) clinical remission (95% confidence interval [CI], 2.12-9.52), 4.15 for remaining free of colectomy (95% CI, 2.53-6.81), 8.40 for achieving long-term MH (95% CI, 3.13-22.53), and 9.70 for achieving long-term corticosteroid-free clinical remission (95% CI, 0.94-99.67), compared with patients without MH1. We found no difference in outcomes if patients achieved MH1 while receiving biologic versus non-biologic therapy. CONCLUSIONS In a meta-analysis, we associated MH with long-term clinical remission, avoidance of colectomy, and corticosteroid-free clinical remission. MH is therefore appropriate goal of UC therapy.
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Affiliation(s)
- Shailja C Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neeraj Narula
- McMaster University Medical Centre, Hamilton, Ontario, Canada
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109
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Kim JH, Cheon JH, Park Y, Lee HJ, Park SJ, Kim TI, Kim WH. Effect of mucosal healing (Mayo 0) on clinical relapse in patients with ulcerative colitis in clinical remission. Scand J Gastroenterol 2016; 51:1069-74. [PMID: 26895215 DOI: 10.3109/00365521.2016.1150503] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to identify the effect of mucosal healing (MH) on clinical relapse in patients with ulcerative colitis (UC) who are in clinical remission, with special reference to Mayo endoscopic subscore 0. METHODS Between November 2005 and December 2013, medical records from a total of 215 patients with UC who underwent colonoscopic examination at the time of clinical remission were retrospectively reviewed. Endoscopic MH was defined as a '0 point' of Mayo endoscopic subscore (Mayo 0). Patients were categorized into two groups according to Mayo endoscopic subscore and then analyzed. RESULTS The baseline characteristics of both groups (MH vs. no-MH), including age at diagnosis, gender, and initial clinical and colonoscopic findings, were not significantly different. The median follow-up duration was 80 (12-118) months. Factors predictive of longer clinical remission duration were age ≥30 years at diagnosis (≥30 years vs. <30 years; hazard ratio [HR] 3.16, 95% CI 1.88-5.30, p < 0.001), shorter interval between diagnosis and clinical remission (<15 months vs. ≥15 months; HR 1.93, 95% CI 1.13-3.28, p = 0.015), and presence of MH at clinical remission (HR 1.95, 95% CI 1.15-3.32, p = 0.014). With a Cox regression model, patients with MH at clinical remission were more likely to have longer duration of clinical remission than patients without MH. CONCLUSION The achievement of MH, Mayo 0 in particular, in patients with UC who are in clinical remission is important in predicting a favorable disease course prognosis.
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Affiliation(s)
- Jae Hyun Kim
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
| | - Jae Hee Cheon
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
| | - Yehyun Park
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
| | - Hyun Jung Lee
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
| | - Soo Jung Park
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
| | - Tae Il Kim
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
| | - Won Ho Kim
- a Department of Internal Medicine and Institute of Gastroenterology , Yonsei University College of Medicine , Seoul , Korea
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110
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Endoscopic Mucosal Healing Predicts Favorable Clinical Outcomes in Inflammatory Bowel Disease: A Meta-analysis. Inflamm Bowel Dis 2016; 22:1859-69. [PMID: 27206015 DOI: 10.1097/mib.0000000000000816] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mucosal healing (MH) in inflammatory bowel disease has been associated with improved long-term clinical outcomes. Uncertainty remains as to the magnitude of this effect and to how this association changes with time and degree of healing. METHODS PubMed, EMBASE, and Web of Science searches identified 1570 citations. Screening of abstracts identified 155 articles for full-text review, of which 19 met inclusion criteria. For 3 outcomes of interest (surgeries, hospitalizations, remission), weighted random-effects meta-analysis was performed. RESULTS In pooled analysis, MH predicted fewer major abdominal surgeries (relative risk [RR], 0.34; 95% confidence interval [CI], 0.26-0.46), increased remission (RR, 1.84; 95% CI, 1.43-2.36), and fewer hospitalizations (RR, 0.58; 95% CI, 0.42-0.78). Complete MH and partial MH both showed significantly higher rates of favorable outcomes. Separate analyses for Crohn's disease and ulcerative colitis showed identical patterns for surgeries and remission. When subjects with no healing were excluded, and complete versus partial healing was compared, rates of surgery were not significantly different (RR, 0.82; 95% CI, 0.46-1.44). However, complete healing was superior in predicting corticosteroid-free remission (RR, 1.71; 95% CI, 1.24-2.34). Meta-regression found that the predictive power of this complete versus partial healing distinction was strongly associated with the duration of follow-up after endoscopy. CONCLUSIONS MH is a strong predictor of fewer surgeries, long-term clinical remission, and fewer hospitalizations. Complete healing is not significantly more favorable than partial healing for predicting surgeries or hospitalizations, but it did predict higher rates of clinical remission. This benefit of complete MH over partial healing increases with follow-up time.
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Langhorst J, Boone J, Lauche R, Rueffer A, Dobos G. Faecal Lactoferrin, Calprotectin, PMN-elastase, CRP, and White Blood Cell Count as Indicators for Mucosal Healing and Clinical Course of Disease in Patients with Mild to Moderate Ulcerative Colitis: Post Hoc Analysis of a Prospective Clinical Trial. J Crohns Colitis 2016; 10:786-94. [PMID: 26874351 DOI: 10.1093/ecco-jcc/jjw044] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 01/25/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We evaluated the performance of blood and faecal biomarkers for differentiating between endoscopic inflammation and mucosal healing, and clinically active disease and sustained clinical remission, and determined the predictive value for a flare in patients with ulcerative colitis [UC]. METHODS Clinical Activity Index [CAI], faecal lactoferrin [FLA], calprotectin [CAL], PMN-elastase [PMN-e], C-reactive protein [CRP], white blood cells [WBC], Endoscopic Index [EI], and UC-Disease Activity Index [DAI] were determined repeatedly during 12 months and at acute flares. RESULTS Of 91 patients [45 female; mean age 48.1±13.4 years] entering in remission, 42 [46%] patients developed a clinical flare. A total of 529 CAI and 179 EI assessments were performed. Median levels for active disease confirmed by EI [n = 35] vs clinical remission with endoscopic inflammation [n = 37] vs mucosal healing [n = 107] for FLA were 44/37/4 µg/g, CAL 25/20/10 µg/g [both p < 0.0001], PMN-e 0.06/0.03/0.02 µg/g, CRP 0.7/0.2/0.2mg/dl [both p < 0.001], and WBC 7.0/6.5/6.4/nl [p = 0.1]. There was no difference for any of the markers for defining mucosal healing by EI = 0 vs EI = 1 with the exception of PMN-e [p = 0.03], where the difference was very small and with questionable clinical relevance. Using manufacturers' cut-offs, only FLA at baseline was associated with a significant higher relative risk [RR] of flaring [RR 1.69; p = 0.018]. Using optimised cut-offs, CAL, PMN-e, and CRP were also predictive of a flare. CONCLUSIONS Faecal biomarkers FLA, CAL, and PMN-e were able to distinguish between UC patients with mucosal healing from clinical remission and mild disease, showed significant correlations with endoscopy, and were predictive of a flare.
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Affiliation(s)
- Jost Langhorst
- Department of Integrative Gastroenterology, Kliniken Essen-Mitte, Essen, Germany Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | | | - Romy Lauche
- Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | | | - Gustav Dobos
- Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
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Pagnini C, Menasci F, Desideri F, Corleto VD, Delle Fave G, Di Giulio E. Endoscopic scores for inflammatory bowel disease in the era of 'mucosal healing': Old problem, new perspectives. Dig Liver Dis 2016; 48:703-8. [PMID: 27050942 DOI: 10.1016/j.dld.2016.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 12/11/2022]
Abstract
The importance of the endoscopic evaluation in inflammatory bowel disease (IBD) management has been recognized for many years. However, the modalities for reporting endoscopic activity represent an ongoing challenge. To address this, several endoscopic scores have been proposed. Very few have been properly validated, and the use of such tools remains sub-optimal and is mainly restricted to clinical trials. In recent years, a growing emphasis of the concept of 'mucosal healing' as a prognostic marker and therapeutic goal has increased the need for a more accurate definition of endoscopic activity in both ulcerative colitis (UC) and Crohn's Disease (CD). In the present review, the evolution of the challenges related to endoscopic scores in IBD has been analyzed, with particular attention paid to the renewed relevance of endoscopic activity in recent years. Currently, despite the growing relevance of endoscopic activity, evaluating this activity in IBD is still a challenge. The implementation of efficacious endoscopic scores and a better definition of the absence of activity (mucosal healing) are needed.
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Affiliation(s)
- Cristiano Pagnini
- "Sapienza" University of Rome, Faculty of Medicine and Psychology, Digestive and Liver Disease Unit, S. Andrea Hospital, Rome, Italy.
| | - Francesca Menasci
- "Sapienza" University of Rome, Faculty of Medicine and Psychology, Digestive and Liver Disease Unit, S. Andrea Hospital, Rome, Italy
| | - Federico Desideri
- "Sapienza" University of Rome, Faculty of Medicine and Psychology, Digestive and Liver Disease Unit, S. Andrea Hospital, Rome, Italy
| | - Vito D Corleto
- Digestive Endoscopy Unit, S. Andrea Hospital, Rome, Italy
| | - Gianfranco Delle Fave
- "Sapienza" University of Rome, Faculty of Medicine and Psychology, Digestive and Liver Disease Unit, S. Andrea Hospital, Rome, Italy
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Fron C, Pierry C, Poullenot F, Chabrun E, Subtil C, Capdepont M, Zerbib F, Belleannée G, Laharie D. Endoscopic and histologic response to cyclosporine in ulcerative colitis and their impact on disease outcome: A cohort study. Dig Liver Dis 2016; 48:734-9. [PMID: 27052254 DOI: 10.1016/j.dld.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cyclosporine (CsA) is an effective agent for treating patients with acute steroid-refractory ulcerative colitis (UC). The aim was to assess endoscopic and histologic responses to CsA and to determine their predictive value on UC outcome. PATIENTS AND METHODS Consecutive UC patients who received intravenous CsA for an acute refractory UC were included when they had endoscopic assessments with biopsies at entry and, at CsA interruption in responders. Mucosal healing (MH) was defined by Mayo endoscopic subscore ≤1 and, histologic response (HR) by the absence of basal plasmocytosis or a Geboes score <3.1. RESULTS Among 21 patients who responded to CsA, MH was achieved in 81%. Survival rates without relapse at 2 years were 79% and 25% in patients with MH and without MH, respectively (p=0.04). HR was observed in 84% of patients according to basal plasmocytosis and in 68% according to Geboes score. Multivariate analysis revealed that a Mayo endoscopic subscore of 0 was the only prognostic factor associated with absence of relapse (RR=12; 95%CI: 1.05-136.79). CONCLUSION CsA provides MH and HR in most of UC patients responding to this drug. As suggested with other UC treatments, a complete MH with CsA has a good prognostic value.
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Affiliation(s)
- Clémence Fron
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Clémence Pierry
- CHU de Bordeaux, Pathology Department, Hôpital Haut-Lévêque, Bordeaux, France
| | - Florian Poullenot
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Edouard Chabrun
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Clément Subtil
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Maylis Capdepont
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Frank Zerbib
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | | | - David Laharie
- CHU de Bordeaux, Gastroenterology Department, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France.
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Nakarai A, Kato J, Hiraoka S, Takashima S, Takei D, Inokuchi T, Sugihara Y, Takahara M, Harada K, Okada H. Ulcerative colitis patients in clinical remission demonstrate correlations between fecal immunochemical test results, mucosal healing, and risk of relapse. World J Gastroenterol 2016; 22:5079-5087. [PMID: 27275100 PMCID: PMC4886383 DOI: 10.3748/wjg.v22.i21.5079] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 03/31/2016] [Accepted: 05/04/2016] [Indexed: 02/07/2023] Open
Abstract
AIM: To assess the risk of relapse in ulcerative colitis (UC) patients in clinical remission using mucosal status and fecal immunochemical test (FIT) results.
METHODS: The clinical outcomes of 194 UC patients in clinical remission who underwent colonoscopy were based on evaluations of Mayo endoscopic subscores (MESs) and FIT results.
RESULTS: Patients with an MES of 0 (n = 94, 48%) showed a ten-fold lower risk of relapse than those with an MES of 1-3 (n = 100, 52%) (HR = 0.10, 95%CI: 0.05-0.19). A negative FIT result (fecal hemoglobin concentrations ≤ 100 ng/mL) was predictive of patients with an MES of 0, with a sensitivity of 0.94 and a specific of 0.76. Moreover, patients with a negative FIT score had a six-fold lower risk of clinical relapse than those with a positive score (HR = 0.17, 95%CI: 0.10-0.28). Inclusion of the distinguishing parameter, sustaining clinical remission > 12 mo, resulted in an even stronger correlation between negative FIT results and an MES of 0 with respect to the risk of clinical relapse (HR = 0.11, 95%CI: 0.04-0.23).
CONCLUSION: Negative FIT results one year or more after remission induction correlate with complete mucosal healing (MES 0) and better prognosis. Performing FIT one year after remission induction may be useful for evaluating relapse risk.
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Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease whose pathogenesis is multifactorial and includes influences from genes, the environment, and the gut microbiome. Recent advances in diagnosis and treatment have led to significant improvement in managing the disease. Disease monitoring with the use of therapeutic drug monitoring, stool markers, and assessment of mucosal healing have garnered much attention. The recent approval of vedolizumab for treatment of moderate to severe UC has been a welcome addition. Newer biologics, including those targeting the Janus tyrosine kinase (JAK) pathway, are on the horizon to add to the current armamentarium of anti-TNF alpha and anti-integrin therapies. The recent publication of the SCENIC consensus statement on surveillance and management of dysplasia in UC patients supports the use of chromoendoscopy over random biopsies in detecting dysplasia. This review highlights these recent advances along with others that have been made with ulcerative colitis.
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Solberg IC, Høivik ML, Cvancarova M, Moum B. Risk matrix model for prediction of colectomy in a population-based study of ulcerative colitis patients (the IBSEN study). Scand J Gastroenterol 2016; 50:1456-62. [PMID: 26139389 DOI: 10.3109/00365521.2015.1064991] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Identifying ulcerative colitis (UC) patients with increased risk of colectomy is essential for appropriate treatment. We aimed to develop a prediction model assessing the risk of having colectomy within the first 10 years after diagnosis. MATERIAL AND METHODS A population-based inception cohort of UC patients diagnosed in south-eastern Norway between 1990 and 1994 has been followed for 10 years. Altogether 519 patients were recruited including 49 patients who were colectomized. Based on the best-fitted multivariate model, the probabilities of colectomy were computed for selected levels of baseline covariates, and the results arranged in a prediction matrix. The following risk factors at diagnosis were analyzed: age, smoking, sex, disease extent, weight loss and fever and need for systemic steroids. Biochemical markers included C-reactive protein (CRP, <30 or ≥30 mg/l); erythrocyte sedimentation rate (ESR, <30 or ≥30 mm/h) and hemoglobin (Hgb, <10.5 or ≥ 10.5 g/dL). RESULTS Extent of disease, age (<40 years, ≥40 years), need for systemic steroids and CRP or ESR (<30 or ≥30) at diagnosis were independently associated with colectomy and were combined in a prediction matrix. The probabilities of colectomy during the follow-up period ranged from 2.6% to 40.1% depending on the combination of predictors at diagnosis. CONCLUSIONS Our prediction model revealed significant differences in the probability of undergoing colectomy during a 10-years course of disease, which supports an early individualized treatment approach in UC.
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Affiliation(s)
- Inger Camilla Solberg
- Department of Gastroenterology, Division of Medicine, Oslo University Hospital , Oslo , Norway
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Zenlea T, Yee EU, Rosenberg L, Boyle M, Nanda KS, Wolf JL, Falchuk KR, Cheifetz AS, Goldsmith JD, Moss AC. Histology Grade Is Independently Associated With Relapse Risk in Patients With Ulcerative Colitis in Clinical Remission: A Prospective Study. Am J Gastroenterol 2016; 111:685-90. [PMID: 26977756 DOI: 10.1038/ajg.2016.50] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/15/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Objective evidence of inflammation has been associated with the risk of relapse in patients with ulcerative colitis (UC) who are in clinical remission. We compared endoscopic and histologic grades for their ability to predict clinical relapse in this patient population. METHODS Patients with UC in clinical remission were prospectively enrolled into an observational cohort. Baseline endoscopic scores (Mayo) and histological (Geboes) grades and blood markers were collected. All subjects were followed for 12 months and relapse determined using clinical indices. RESULTS A total of 179 subjects were enrolled into the study and followed for 12 months. Clinical relapse occurred in 23%; 5% were hospitalized, and 2% underwent colectomy. In univariate analysis, the baseline Mayo endoscopy score and the Geboes histology grade were significantly associated with the later development of clinical relapse (P<0.001 for both), but only the histology grade remained significant in a multivariate model (P=0.006). The relative risk of clinical relapse was 3.5 (95% CI 1.9-6.4, P<0.0001) in subjects whose baseline Geboes grade was ≥3.1. The area under the curve was 0.73 for the Geboes histology grade to identify subjects at risk of future clinical relapse. Of the patients in clinical, endoscopic, and histological remission at baseline (n=82), only 7% had a clinical relapse over the subsequent 12 months. CONCLUSIONS Histology grade has the strongest association with the risk of clinical relapse in patients with UC who are in clinical remission. Consideration should be given to including this end point in evaluating therapy for UC.
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Affiliation(s)
- Talia Zenlea
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Eric U Yee
- Department of Pathology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Rosenberg
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Marie Boyle
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Kavinderjit S Nanda
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Jacqueline L Wolf
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth R Falchuk
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey D Goldsmith
- Department of Pathology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Alan C Moss
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
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118
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Abstract
BACKGROUND Mucosal healing in ulcerative colitis leads to a decreased need for medication and decreased risk of disease relapse and colectomy. Histological healing seems to improve the disease prognosis even further. An assessment of both endoscopic and histological mucosal healing requires endoscopy, and the need for a reliable noninvasive biomarker to predict disease relapse is obvious. METHODS Seventy patients were included and followed up for 12 months. Inclusion criteria were a total Mayo score ≤1 and a Mayo endoscopic score = 0. The patients underwent sigmoidoscopy with rectal biopsies. Fecal calprotectin (FC) was measured 2 to 3 days before the sigmoidoscopy. The tissue samples were evaluated for neutrophilic inflammation. We aimed at testing the predictive performance of FC and histological inflammatory activity on disease relapse. RESULTS A baseline FC level of more than 321 mg/kg predicted disease relapse at both the 6- and 12-month follow-ups. Histological inflammatory activity, C-reactive protein, or length of remission was not predictive of relapse. Of note, 11.8% of all patients had histological inflammatory activity despite endoscopic remission and were found to have a higher level of FC (236.5 versus 56 mg/kg, P = 0.02). A receiver operating characteristic analysis estimated a cutoff level of ≤40.5 mg/kg for FC (area under the curve, 0.755 and confidence interval 95%, 0.5895-0.9208) for predicting a histological inflammatory activity score of 0. CONCLUSIONS FC measurements can be used to identify patients with increased risk of relapse after 6 and 12 months and to predict histological mucosal healing. Regular measurement of FC may alter disease monitoring and improve prognosis, and may decrease the need for endoscopy.
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Abstract
INTRODUCTION Advances in immuno-modulatory therapies, including anti-TNF-α therapies, have greatly increased the chance to achieve long-term remission of inflammatory bowel disease (IBD) patients. However, as the importance of mucosal healing has been demonstrated in a number of clinical studies, new cell-based therapies that can regenerate and fully restore the intestinal mucosal functions are currently under development. AREA COVERED In this review, we feature the recent challenges of cell-based therapies that are applied to the treatment of IBD. In particular, we will focus on hematopoietic stem cells (HSC), mesenchymal stem cells (MSCs) and intestinal stem cells (ISCs) as the candidate source for cell-based therapy targeted to treat IBD. The current status, as well as the expected advantages and disadvantages of those transplantations will be summarized and discussed. EXPERT OPINION Transplantation of HSC, MSC and ISC may have different levels of potential in their ability to exert an immunomodulatory or pro-regenerative effect. Combined cell therapies, such as co-transplantation of MSC and ISC, may provide improved therapeutic outcome compared to transplantation of a single cell population. Those cell-based therapies may not only improve the disease activity or tissue regeneration, but may also have the potential to decrease the risk of developing colitis-associated cancers.
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Affiliation(s)
- Ryuichi Okamoto
- a Center for Stem Cell and Regenerative Medicine , Tokyo Medical and Dental University , Tokyo , Japan
| | - Mamoru Watanabe
- b Department of Gastroenterology and Hepatology, Graduate School , Tokyo Medical and Dental University , Tokyo , Japan
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Muñoz Villafranca C, Bravo Rodríguez MT, Ortiz de Zárate J, Arreba González P, García Kamiruaga I, Heras Martín JI, Cabezudo Gil P, Orive Cura V. [Clinical outcome after discontinuation of infliximab in patients with ulcerative colitis in deep remission]. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:442-8. [PMID: 26948837 DOI: 10.1016/j.gastrohep.2015.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Infliximab (IFX) is effective in treating ulcerative colitis (UC) and in achieving mucosal healing (MH). Little is known about the role of mucosal healing (MH) in the subsequent evolution of the disease and the consequences of discontinuing treatment. AIMS To evaluate the characteristics and evolution of patients with UC treated with IFX who discontinued treatment after disease remission. METHODS Observational, prospective study of patients with moderate to severe UC, corticosteroid-resistant/corticosteroid-dependent, naïve to anti-TNF. IFX administration regimen: 5 mg/kg at 0-2-6 weeks and every 8 weeks thereafter until week 54. In patients achieving MH, IFX was discontinued and the patients were followed-up for at least 20 months. Clinical remission (CR): mayo score <2; Clinical response: decrease in mayo score of 3 points; MH: mayo score 0-1; Deep remission: patient with CR and MH. RESULTS Of the 21 patients enrolled, 19 completed the study (colectomy, n = 1; non-responder, n = 1). Mean age: 47.8 years. UC: severe (n = 13) and moderate (n = 6); most patients (n = 11) were steroid-resistant; 57.8% received combined treatment with immunosuppressants, and 31.5% intensified treatment. Week 54: 16 patients (84.2%) showed clinical response, 13 (68.4%) showed CR, and 12 (63.2%) deep remission. Of these, 6 (25%) presented a new episode of UC, and in 3 (25%) IFX was restarted within 12 weeks of discontinuation, with all patients responding. Of the total sample, 91.7% remained IFX-free at week 8, and 75% at week 12, with no remission during follow-up. None of the patients required hospitalization or surgery. CONCLUSIONS Half of patients with deep remission of UC with IFX therapy presented a new episode after treatment discontinuation, and in 25% IFX therapy was restarted.
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Affiliation(s)
| | | | | | | | | | | | - Pilar Cabezudo Gil
- Servicio de Digestivo, Hospital Universitario de Basurto, Bilbao, España
| | - Víctor Orive Cura
- Servicio de Digestivo, Hospital Universitario de Basurto, Bilbao, España
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Zakko SF, Gordon GL, Murthy U, Sedghi S, Pruitt R, Barrett AC, Bortey E, Paterson C, Forbes WP, Lichtenstein GR. Once-daily mesalamine granules for maintaining remission of ulcerative colitis: pooled analysis of efficacy, safety, and prognostic factors. Postgrad Med 2016; 128:273-81. [PMID: 26861051 DOI: 10.1080/00325481.2016.1152876] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES A capsule formulation of mesalamine granules (MG) was developed for once-daily dosing and better compliance. The study aim was to evaluate MG efficacy and tolerability in maintaining ulcerative colitis (UC) remission. METHODS Pooled analysis of 2 identical phase 3, randomized, double-blind trials of once-daily MG 1.5 g or placebo for up to 6 months. The primary endpoint was percentage of patients remaining relapse-free at month 6 versus placebo. Relapse was defined as revised Sutherland Disease Activity Index (SDAI) rectal bleeding score ≥1 and mucosal appearance score ≥2, UC flare, or UC-related adverse event (AE). RESULTS Data were pooled for patients receiving MG (n = 373) and placebo (n = 189). Significantly more patients were relapse-free at 6 months with MG (79.4%) than placebo (62.4%; P < 0.001) and across subgroups based on select demographic and baseline characteristics (P < 0.05). Secondary outcome measures including rectal bleeding, physician rating of disease activity, stool frequency, total SDAI score, and relapse-free duration favored MG (P < 0.01). Common AEs with MG and placebo, respectively, were headache (10.9% and 7.6%), diarrhea (7.9% and 7.0%), and abdominal pain (6.3% and 6.5%). CONCLUSION Once-daily MG was more efficacious than and as well tolerated as placebo in maintaining UC remission. ClinicalTrials.gov identifiers: NCT00744016 and NCT00767728.
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Affiliation(s)
- Salam F Zakko
- a Connecticut Gastroenterology Institute , Bristol Hospital , Bristol , Connecticut , USA
| | - Glenn L Gordon
- b Center for Digestive and Liver Diseases, Inc ., Mexico , Missouri , USA
| | - Uma Murthy
- c Department of Medicine , Syracuse VA Medical Center , Syracuse , New York , USA
| | - Shahriar Sedghi
- d Gastroenterology Associates of Central Georgia, LLC , Macon , Georgia , USA
| | - Ronald Pruitt
- e Nashville Medical Research Institute and The Maria Nathanson Center at Saint Thomas Hospital , Nashville , Tennessee , USA
| | - Andrew C Barrett
- f Salix, a Division of Valeant Pharmaceuticals North America LLC , Bridgewater , NJ , USA
| | - Enoch Bortey
- f Salix, a Division of Valeant Pharmaceuticals North America LLC , Bridgewater , NJ , USA
| | - Craig Paterson
- f Salix, a Division of Valeant Pharmaceuticals North America LLC , Bridgewater , NJ , USA
| | - William P Forbes
- f Salix, a Division of Valeant Pharmaceuticals North America LLC , Bridgewater , NJ , USA
| | - Gary R Lichtenstein
- g Department of Medicine , University of Pennsylvania School of Medicine , Philadelphia , Pennsylvania , USA
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Ikeya K, Hanai H, Sugimoto K, Osawa S, Kawasaki S, Iida T, Maruyama Y, Watanabe F. The Ulcerative Colitis Endoscopic Index of Severity More Accurately Reflects Clinical Outcomes and Long-term Prognosis than the Mayo Endoscopic Score. J Crohns Colitis 2016; 10:286-95. [PMID: 26581895 PMCID: PMC4957474 DOI: 10.1093/ecco-jcc/jjv210] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and the Mayo endoscopic score (Mayo ES) are used to evaluate ulcerative colitis (UC) severity. This study compared UCEIS and the Mayo ES for evaluating UC severity and outcomes in patients undergoing remission induction during routine clinical practice with the aim of predicting medium- to long-term prognosis. METHODS Forty-one UC patients who received colonoscopy before and after tacrolimus remission induction therapy were included. An index of clinical activity and endoscopic findings scored by both the UCEIS and the Mayo ES were determined. Changes in UCEIS and Mayo ES before and after induction therapy were compared. RESULTS The mean UCEIS improved from 6.2±0.9 to 3.4±2.1 (p < 0.001). Based on the UCEIS, a significant reduction was reached in both the response and the remission groups. In contrast, the Mayo ES did not reflect a significant change in the response group. The discrepancy appeared to be due to ulcers becoming smaller and shallower during the early stages of mucosal healing; the Mayo ES seems to miss these early changes. In other words, whereas the UCEIS indicates improvements when ulcers shrink, the Mayo ES does not distinguish deep ulcers from shallow ulcers and is 3 (severe UC) for both deep and shallow ulcers. Additionally, better UCEIS strata after induction therapy were associated with lower incidences of colectomy (p = 0.0001) or relapse (p = 0.0008). CONCLUSIONS The UCEIS accurately reflects clinical outcomes and predicts the medium- to long-term prognosis in UC patients undergoing induction therapy. These findings should support decision-making in clinical practice settings.
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Affiliation(s)
- Kentaro Ikeya
- Centre for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Hiroyuki Hanai
- Centre for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Ken Sugimoto
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoshi Osawa
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shinsuke Kawasaki
- Centre for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Takayuki Iida
- Centre for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Yasuhiko Maruyama
- Department of Gastroenterology, Fujieda Municipal General Hospital, Fujieda, Japan
| | - Fumitoshi Watanabe
- Centre for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
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Cintolo M, Costantino G, Pallio S, Fries W. Mucosal healing in inflammatory bowel disease: Maintain or de-escalate therapy. World J Gastrointest Pathophysiol 2016; 7:1-16. [PMID: 26909224 PMCID: PMC4753175 DOI: 10.4291/wjgp.v7.i1.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 11/16/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
In the past decade, thanks to the introduction of biologic therapies, a new therapeutic goal, mucosal healing (MH), has been introduced. MH is the expression of an arrest of disease progression, resulting in minor hospitalizations, surgeries, and prolonged clinical remission. MH may be achieved with several therapeutic strategies reaching success rates up to 80% for both, ulcerative colitis (UC) and Crohn’s disease (CD). Various scoring systems for UC and for the transmural CD, have been proposed to standardize the definition of MH. Several attempts have been undertaken to de-escalate therapy once MH is achieved, thus, reducing the risk of adverse events. In this review, we analysed the available studies regarding the achievement of MH and the subsequent treatment de-escalation according to disease type and administered therapy, together with non-invasive markers proposed as predictors for relapse. The available data are not encouraging since de-escalation after the achievement of MH is followed by a high number of clinical relapses reaching up to 50% within one year. Unclear is also another question, in case of combination therapies, which drug is more appropriate to stop, in order to guarantee a durable remission. Predictors of unfavourable outcome such as disease extension, perianal disease, or early onset disease appear to be inadequate to foresee behaviour of disease. Further studies are warranted to investigate the role of histologic healing for the further course of disease.
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Christensen B, Rubin DT. Understanding Endoscopic Disease Activity in IBD: How to Incorporate It into Practice. Curr Gastroenterol Rep 2016; 18:5. [PMID: 26759147 DOI: 10.1007/s11894-015-0477-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Endoscopic assessment of disease activity is an essential part of clinical practice in inflammatory bowel disease (IBD) and is used for diagnosis, prognosis, monitoring for dysplasia and increasingly for the evaluation of mucosal or endoscopic response to therapy. Recently, mucosal or endoscopic healing has emerged as a key goal of therapy as it has been found that patients who achieve endoscopic remission have improved outcomes compared to those who do not, and this may be independent of their clinical disease activity. However, there is currently no validated definition of mucosal healing and there are numerous endoscopic scoring systems proposed to define endoscopic activity and response to therapy in both ulcerative colitis and Crohn's disease. This article will discuss the most common endoscopic scores used to measure endoscopic disease activity in IBD, the pros and cons of each of these scoring systems and proposed definitions for endoscopic response or remission that exist for each. In addition, the role of endoscopy in prognosticating the disease course is discussed and how endoscopy can be utilized as part of a "treat-to-target" treatment strategy where endoscopy results direct decisions regarding medical strategies in clinical practice is highlighted.
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Affiliation(s)
- Britt Christensen
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Ave., MC4076, Room M410, Chicago, IL, 60637, USA
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Australia
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Ave., MC4076, Room M410, Chicago, IL, 60637, USA.
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125
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Okamoto R, Watanabe M. Role of epithelial cells in the pathogenesis and treatment of inflammatory bowel disease. J Gastroenterol 2016; 51:11-21. [PMID: 26138071 DOI: 10.1007/s00535-015-1098-4] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 06/15/2015] [Indexed: 02/04/2023]
Abstract
In the past decades, continuous effort has been paid to deeply understanding the pathophysiology of inflammatory bowel diseases (IBD), such as ulcerative colitis or Crohn's disease. As the disease typically arises as chronic inflammation of the gastrointestinal mucosa, research has been focused on how such an uncontrolled, deleterious immune response may arise and persist in a certain cohort of patients. Based on those immunologic analyses, the establishment of anti-TNF-α therapy, and the following series of biologic agents achieved great success and dramatically changed the therapeutic strategy of IBD patients. However, to guarantee long-term remission of the disease, the therapeutic standard has been raised to achieve "mucosal healing", which requires complete repair of the gastrointestinal mucosa. Recent studies have revealed the unexpected importance of epithelial cells in the pathophysiology of IBD. The general barrier function as well as the cell lineage-specific functions have been deeply attributed to the development of chronic intestinal inflammation. Also, the groundbreaking establishment of the in vitro intestinal stem cell culture system has opened up a way of developing stem cell transplantation therapy to treat otherwise refractory ulcers that may persist in IBD patients. In this review, we would like to focus on the role of epithelial cells in the pathophysiology of IBD, and also give a perspective to the upcoming development of regenerative therapies that may become one of the therapeutic choices to achieve mucosal healing in refractory patients of IBD.
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Affiliation(s)
- Ryuichi Okamoto
- Center for Stem Cell and Regenerative Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Boal Carvalho P, Dias de Castro F, Rosa B, Moreira MJ, Cotter J. Mucosal Healing in Ulcerative Colitis--When Zero is Better. J Crohns Colitis 2016; 10:20-5. [PMID: 26438714 DOI: 10.1093/ecco-jcc/jjv180] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/28/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Extensive evidence has underlined the importance of mucosal healing as a treatment aim for ulcerative colitis (UC). We aimed to assess differences in the incidence of clinical relapse at 12 months between UC patients with Mayo endoscopic scores (MES) 0 and 1. METHODS This retrospective study included consecutive patients in corticosteroid-free remission between 2008 and 2013 and with follow-up of at least 1 year, with MES 0 or 1 in complete colonoscopy. Clinical relapse was defined as need for induction treatment, treatment escalation, hospitalization or surgery. A p value <0.05 was considered statistically significant. RESULTS The study included 138 patients, 72 (52.2%) female, with mean age of 49 (±14) years. Inflammatory activity was classified as MES 0 in 61 (44.2%) patients and MES 1 in 77 (55.8%) patients. Clinical relapse during follow-up was significantly more frequent in patients with MES 1 than MES 0 (27.3 vs 11.5%, p = 0.022), and in the multivariate analysis MES 1 was the only factor significantly associated with an increased risk of relapse (odds ratio 2.89, 95% confidence interval 1.14-7.36, p = 0.026). This association was encountered in the subgroup of patients with left-sided/extensive colitis (29.7 vs 11.1%, p = 0.049), but not proctitis (25.0 vs 12.0%, p = 0.202). CONCLUSIONS In patients with UC in corticosteroid-free remission, particularly those with left-sided colitis or extensive colitis, MES 1 was significantly associated with a 3-fold increased risk of relapse compared with endoscopic MES 0. Our results support the use of endoscopic MES 0 as the most suitable treatment endpoint to define mucosal healing in patients with UC.
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Affiliation(s)
- Pedro Boal Carvalho
- Hospital Senhora da Oliveira - Guimarães, Rua dos Cutileiros, Creixomil, 4831-044, Guimarães, Portugal
| | - Francisca Dias de Castro
- Hospital Senhora da Oliveira - Guimarães, Rua dos Cutileiros, Creixomil, 4831-044, Guimarães, Portugal
| | - Bruno Rosa
- Hospital Senhora da Oliveira - Guimarães, Rua dos Cutileiros, Creixomil, 4831-044, Guimarães, Portugal
| | - Maria João Moreira
- Hospital Senhora da Oliveira - Guimarães, Rua dos Cutileiros, Creixomil, 4831-044, Guimarães, Portugal
| | - José Cotter
- Hospital Senhora da Oliveira - Guimarães, Rua dos Cutileiros, Creixomil, 4831-044, Guimarães, Portugal Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Campus Gualtar, 4710-057, Braga, Portugal ICVS/3B's, PT Government Associate Laboratory, 4710-057 Guimarães/Braga, Portugal
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Yamaguchi S, Takeuchi Y, Arai K, Fukuda K, Kuroki Y, Asonuma K, Takahashi H, Saruta M, Yoshida H. Fecal calprotectin is a clinically relevant biomarker of mucosal healing in patients with quiescent ulcerative colitis. J Gastroenterol Hepatol 2016. [PMID: 26212346 DOI: 10.1111/jgh.13061] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Calprotectin is an abundant protein in neutrophils, which infiltrate the mucosa during inflammation. Fecal calprotectin (FC) level has shown correlation with disease activity in ulcerative colitis (UC) patients. Additionally, FC level is expected to indicate mucosal healing (MH). This study was to see the significance of FC for predicting MH in patients with quiescent UC. METHODS A total of 112 patients with quiescent UC were included. After taking blood and stool samples, patients underwent total colonoscopy, and the Mayo endoscopic subscore was recorded. FC was measured by fluorescence enzyme immunoassay. C-reactive protein, hemoglobin, erythrocyte sedimentation rate, and serum albumin were measured as conventional biomarkers. MH was defined as Mayo 0 or 0 and 1, and receiver-operator characteristic analyses were undertaken to determine the significance levels of measurements. RESULTS Data from 105 patients were available. Eleven patients showed Mayo ≥ 2. The median (interquartile range) of FC level of all patients was 115 µg/g (45.4-420). The area under the curve (AUC) in receiver operator characteristic analysis of FC to predict Mayo 0 and 1 was 0.869 with a cut-off value of 200 µg/g yielding 67% sensitivity and 91% specificity, which were the best among all biomarkers. However, the power of FC to predict Mayo 0 was modest; the AUC was 0.639 and cut-off value 194 µg/g with 71% sensitivity and 58% specificity. CONCLUSIONS Based on the findings of this study, we believe that FC is a clinically relevant biomarker of MH in patients with quiescent UC. Other favorable features of FC test include feasibility and non-invasiveness.
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Affiliation(s)
- Sayaka Yamaguchi
- Department of Internal Medicine, Division of Gastroenterology, Showa University, School of Medicine, Tokyo, Japan
| | - Yoshiaki Takeuchi
- Department of Internal Medicine, Division of Gastroenterology, Showa University, School of Medicine, Tokyo, Japan
| | - Katsuhito Arai
- Department of Internal Medicine, Division of Gastroenterology, Showa University, School of Medicine, Tokyo, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St Luke's International Hospital, Tokyo, Japan
| | - Yuichiro Kuroki
- Division of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kunio Asonuma
- Division of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroshi Takahashi
- Division of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Masayuki Saruta
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hitoshi Yoshida
- Department of Internal Medicine, Division of Gastroenterology, Showa University, School of Medicine, Tokyo, Japan
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Simsek HD, Basyigit S, Aktas B, Simsek GG, Vargol E, Kucukazman M, Nazlıgul Y. Assessment of the Correlation between Endoscopic Activity and Histological Activity in Ulcerative Colitis Patients. Med Princ Pract 2016; 25:378-84. [PMID: 26985865 PMCID: PMC5588425 DOI: 10.1159/000445502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 03/16/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess the concordance between the Rachmilewitz endoscopic activity index (EAI) and the Harpaz histopathological activity scoring system (HSS), which are used for evaluating the disease activity of ulcerative colitis (UC). SUBJECTS AND METHODS This study included 109 patients with UC. Based on the disease extent, patients were divided into two groups as left-sided colitis and pancolitis. Patients were grouped as inactive, mild, moderate and severe depending on the Rachmilewitz EAI and Harpaz HSS. Kendal's tau and kappa (x03BA;) statistics were used to assess the agreement between endoscopic and histopathological scores. A receiver operating characteristic (ROC) curve was also analyzed to evaluate the sensitivity and specificity of endoscopic scores to predict inactive histopathological disease. RESULTS In the left-sided colitis group, there were slight and poor agreements in the inactive endoscopic subscores (ESS) with inactive Harpaz HSS (x03BA;: 0.598, p < 0.001) and moderate ESS with moderate Harpaz HSS (x03BA;: 0.236, p = 0.046). There was no agreement between mild ESS and mild Harpaz HSS and between severe ESS and severe Harpaz HSS (x03BA;: 0.071, p = 0.573 and x03BA;: 0.160, p = 0.151, respectively). In the pancolitis group, there was no significant agreement between inactive, mild, moderate and severe ESS and the equivalent Harpaz HSS grades (x03BA;: -0.194, p = 0.187; x03BA;: 0.125, p = 0.397; x03BA;: 0.148, p = 0.175 and x03BA;: 0.174, p = 0.153, respectively). The ROC curve showed that the ESS indicating inactive disease had a low sensitivity to predict histologically inactive disease. CONCLUSION The concordance between the endoscopic and histopathological indices was poor. Using both scores in the follow-up of patients with UC is necessary for treatment planning.
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Affiliation(s)
- Hulya Demirkaynak Simsek
- Department of Pathology, Ankara, Turkey
- *Hulya Demirkaynak Simsek, Department of Pathology, Keçiören Training and Research Hospital, Pìnarbaşì Mah. Sanatoryum Cad. Ardahan Sok. No. 25, TR—06380 Ankara (Turkey), E-Mail
| | - Sebahat Basyigit
- Department of Gastroenterology, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Bora Aktas
- Department of Gastroenterology, Keçiören Training and Research Hospital, Ankara, Turkey
| | | | | | - Metin Kucukazman
- Department of Gastroenterology, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Yaşar Nazlıgul
- Department of Gastroenterology, Keçiören Training and Research Hospital, Ankara, Turkey
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Kato J, Hiraoka S, Nakarai A, Takashima S, Inokuchi T, Ichinose M. Fecal immunochemical test as a biomarker for inflammatory bowel diseases: can it rival fecal calprotectin? Intest Res 2016; 14:5-14. [PMID: 26884729 PMCID: PMC4754522 DOI: 10.5217/ir.2016.14.1.5] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 10/09/2015] [Accepted: 10/10/2015] [Indexed: 12/13/2022] Open
Abstract
Accurate evaluation of disease activity is essential for choosing an appropriate treatment and follow-up plan for patients with inflammatory bowel disease (IBD). Endoscopy is required for accurately evaluating disease activity, but the procedures are sometimes invasive and burdensome to patients. Therefore, alternative non-invasive methods for evaluating or predicting disease activity including mucosal status are desirable. Fecal calprotectin (Fcal) is the most widely used fecal marker for IBD, and many articles have described the performance of the marker in predicting disease activity, mucosal healing (MH), treatment efficacy, and risk of relapse. Fecal immunochemical test (FIT) can quantify the concentration of hemoglobin in stool and was originally used for the screening of colorectal cancer. We recently reported that FIT is also a useful biomarker for IBD. A direct comparison between the use of Fcal and FIT showed that both methods predicted MH in ulcerative colitis equally well. However, in the case of Crohn's disease, FIT was less sensitive to lesions in the small intestine, compared to Fcal. FIT holds several advantages over Fcal in regards to user-friendliness, including a lower cost, easy and clean handling, and the ability to make rapid measurements by using an automated measurement system. However, there is insufficient data to support the application of FIT in IBD. Further studies into the use of FIT for evaluating the inflammatory status of IBD are warranted.
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Affiliation(s)
- Jun Kato
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Sakiko Hiraoka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Asuka Nakarai
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shiho Takashima
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshihiro Inokuchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masao Ichinose
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Fernandes C, Allocca M, Danese S, Fiorino G. Progress with anti-tumor necrosis factor therapeutics for the treatment of inflammatory bowel disease. Immunotherapy 2015; 7:175-90. [PMID: 25713992 DOI: 10.2217/imt.14.105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Anti-tumor necrosis factor (TNF) therapy is a valid, effective and increasingly used option in inflammatory bowel disease management. Nevertheless, further knowledge and therapeutic indications regarding these drugs are still evolving. Anti-TNF therapy may be essential to achieve recently proposed end points, namely mucosal healing, prevention of bowel damage and prevention of patient's disability. Anti-TNF drugs are also suggested to be more effective in early disease, particularly in early Crohn's disease. Moreover, its efficacy for prevention of postoperative recurrence in Crohn's disease is still debated. Costs and adverse effects, the relevance of drug monitoring and the possibility of anti-TNF therapy withdrawal in selected patients are still debated issues. This review aimed to describe and discuss the most relevant data about the progress with anti-TNF therapy for the management of inflammatory bowel disease.
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Affiliation(s)
- Carlos Fernandes
- Department of Gastroenterology, Centro Hospitalar Vila Nova Gaia, Porto, Portugal
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131
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Trivedi I, Hanauer SB. Balancing the risks and benefits of biologic therapy in inflammatory bowel diseases. Expert Opin Drug Saf 2015; 14:1915-34. [PMID: 26559664 DOI: 10.1517/14740338.2015.1108961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The incidence of Inflammatory Bowel Diseases (IBD) is rising and overall epidemiology is changing. Goals of IBD therapy are also fast changing to reflect the concept of mucosal healing. IBD management is increasingly revolving around questions of ideal positioning of biologic therapies. AREAS COVERED This paper covers important concepts regarding two classes of biologic medications approved for treatment of IBD in the United States - anti-TNF-α agents and lymphocyte-homing antagonists. Topics covered include drug mechanism of action, pharmacokinetic considerations for the clinician including therapeutic drug monitoring, summary of current evidence of drug efficacy in IBD focusing on randomized, controlled trial data. Additionally, nuanced discussion of medication side-effects and adverse reactions is presented. EXPERT OPINION Paradigms of treatment goals in IBD are changing with increasing focus on mucosal healing. Concomitantly, our understanding of important factors that impact drug pharmacokinetic/pharmacodynamics relationships with biologic agents has increased which will help eventually develop personalized algorithms to optimize the efficacy of these agents. Though direct head-to-head comparisons between these agents are lacking, biologic agents can be considered the safest and most effective therapies introduced for IBD.
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Affiliation(s)
- Itishree Trivedi
- a Division of Gastroenterology and Hepatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Stephen B Hanauer
- a Division of Gastroenterology and Hepatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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Jharap B, Sandborn WJ, Reinisch W, D'Haens G, Robinson AM, Wang W, Huang B, Lazar A, Thakkar RB, Colombel J. Randomised clinical study: discrepancies between patient-reported outcomes and endoscopic appearance in moderate to severe ulcerative colitis. Aliment Pharmacol Ther 2015; 42:1082-92. [PMID: 26381802 PMCID: PMC5049645 DOI: 10.1111/apt.13387] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 05/24/2015] [Accepted: 08/10/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Associations between patient-reported outcomes and mucosal healing have not been established in ulcerative colitis (UC). AIM To evaluate relationships of rectal bleeding and stool frequency with mucosal healing and quality of life (QoL) in patients with UC in two Phase 3 studies (ULTRA 1 and 2). METHODS Associations of patient-reported rectal bleeding and stool frequency subscores with mucosal healing (Mayo endoscopy subscore = 0 or 0/1) and QoL [inflammatory bowel disease questionnaire (IBDQ)] were assessed in adalimumab-randomised patients (160/80 mg at Weeks 0/2 followed by 40 mg biweekly or weekly) at Weeks 8 (n = 433) and 52 (n = 299), and in patients with mucosal healing [endoscopy subscore = 0 (n = 17); 0/1 (n = 52)] at Weeks 8 and 52. RESULTS At Week 8, the positive predictive values (PPVs) of rectal bleeding subscore = 0, stool frequency subscore = 0 or both scores = 0 for endoscopy subscore = 0/1 were 69%, 84% and 90% respectively; all proportions increased at Week 52. Equivalent PPVs for these subscores in patients with endoscopy subscore = 0 were 26%, 37% and 46% respectively. Among patients with endoscopy subscore = 0 at Week 8, 87% reported no rectal bleeding, while only 29% reported normal stool frequency; these proportions had increased to 94% and 41% respectively, at Week 52. Among patients with mucosal healing, IBDQ scores trended highest for patients with both rectal bleeding and stool frequency subscores = 0. CONCLUSIONS Absence of rectal bleeding and normal stool frequency are often predictive of mucosal healing and QoL, but complete normalisation of stool frequency is encountered rarely in patients with mucosal healing.
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Affiliation(s)
- B. Jharap
- The Dr Henry D. Janowitz Division of GastroenterologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - W. J. Sandborn
- Inflammatory Bowel Disease CenterDivision of GastroenterologyUniversity of California San DiegoLa JollaCAUSA
| | - W. Reinisch
- Department of GastroenterologyMcMaster UniversityHamiltonONCanada
- Department of Gastroenterology and HepatologyMedical University of ViennaViennaAustria
| | - G. D'Haens
- Department of GastroenterologyAcademic Medical CenterAmsterdamThe Netherlands
| | | | - W. Wang
- AbbVie Inc.North ChicagoILUSA
| | | | - A. Lazar
- AbbVie Deutschland GmbH & Co. KGLudwigshafenGermany
| | | | - J.‐F. Colombel
- The Dr Henry D. Janowitz Division of GastroenterologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
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Theede K, Holck S, Ibsen P, Ladelund S, Nordgaard-Lassen I, Nielsen AM. Level of Fecal Calprotectin Correlates With Endoscopic and Histologic Inflammation and Identifies Patients With Mucosal Healing in Ulcerative Colitis. Clin Gastroenterol Hepatol 2015; 13:1929-36.e1. [PMID: 26051392 DOI: 10.1016/j.cgh.2015.05.038] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/11/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS In patients with ulcerative colitis (UC), mucosal healing is an important goal of treatment. However, mucosal healing is difficult to determine on the basis of clinical evaluation alone, and endoscopy is uncomfortable and can cause complications. Fecal calprotectin (FC) is a marker of inflammation, and its levels have been associated with disease activity. We investigated the association between level of FC and mucosal healing and clinical disease activity in patients with UC. METHODS We performed an observational cross-sectional study of 120 patients with active or inactive UC who underwent sigmoidoscopy at Copenhagen University Hospital Hvidovre from September 2012 through 2014. Endoscopic inflammation was evaluated by using the Mayo Endoscopic Score (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and histologic inflammatory activity by a slightly modified Harpaz Index, which measures acute inflammation. The Partial Mayo Score was used to measure the clinical disease activity. RESULTS A cutoff level of FC of 192 mg/kg identified patients with endoscopic evidence of mucosal healing, which was based on the MES and UCEIS, with positive predictive values of 0.71 and 0.65, respectively; negative predictive values were 0.90 and 0.93, respectively. A cutoff level of 171 mg/kg identified patients with histologic evidence of mucosal healing, with positive predictive value of 0.75 and negative predictive value of 0.90. Levels of FC increased significantly with increases in endoscopic and histologic disease activity. There was high concordance between MES and UCEIS as well as between MES or UCEIS and histologic inflammatory activity. The histologic activity index had an interobserver variation of 4.35%. CONCLUSIONS Level of FC identifies patients with UC who have endoscopic and histologic features of mucosal healing and correlates with endoscopic and histologic inflammatory activity. The UCEIS seems to be as accurate as the MES in identifying patients with mucosal healing and as easy to use. The histologic activity index had a high concordance with recognized endoscopic score systems.
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Affiliation(s)
- Klaus Theede
- Gastrounit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Susanne Holck
- Department of Pathology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Per Ibsen
- Department of Pathology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Steen Ladelund
- Clinical Research Center, Department of Statistics, Copenhagen University Hospital, Hvidovre, Denmark
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Abstract
BACKGROUND Thiopurines are effective drugs in treating ulcerative colitis (UC) and Crohn's disease (CD) even if studies that specifically investigate these drugs' profile of efficacy in UC compared with CD are scarce. Our aim was to compare the profile of efficacy of thiopurines in patients with UC and CD. METHODS We perfomed a longitudinal observational study evaluating steroid-free clinical remission (CR) and mucosal healing (MH) in all patients with UC and CD who would complete 2 years of maintenance treatment with thiopurines. In patients with UC, CR and MH were assessed before starting treatment and 2 years later using the Mayo score (CR = Mayo score <2; MH = Mayo subscore ≤1). In patients with CD, CR and MH were assessed at the same time points using the Crohn's disease activity index (CR = Crohn's disease activity index < 150) and the Simplified Endoscopic Score for Crohn's Disease (MH = Simplified Endoscopic Score for Crohn's Disease < 2). The efficacy of thiopurines was assessed through intention-to-treat and per-protocol analyses. RESULTS The study included 205 steroid-dependent patients (104 UC; 101 CD), 140 of whom (70 UC; 70 CD) completed the 2-year observation period. Steroid-free CR was recorded in 43 patients with UC and 37 with CD (intention-to-treat: 41% versus 36%; P = 0.6; per-protocol: 61% versus 53%; P = 0.4); MH was obtained in 38 patients with UC and 17 with CD (intention-to-treat: 36% versus 16%; P < 0.01; odds ratio, 2.9; per-protocol: 54% versus 25%; P < 0.01; odds ratio, 3.7). CONCLUSIONS Thiopurines are effective in maintaining steroid-free CR in both UC and CD although they show a better profile of efficacy in terms of MH in cases of UC.
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Lobatón T, Bessissow T, De Hertogh G, Lemmens B, Maedler C, Van Assche G, Vermeire S, Bisschops R, Rutgeerts P, Bitton A, Afif W, Marcus V, Ferrante M. The Modified Mayo Endoscopic Score (MMES): A New Index for the Assessment of Extension and Severity of Endoscopic Activity in Ulcerative Colitis Patients. J Crohns Colitis 2015; 9:846-52. [PMID: 26116558 DOI: 10.1093/ecco-jcc/jjv111] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/01/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Current endoscopic activity scores for ulcerative colitis (UC) do not take into account the extent of mucosal inflammation. We have developed a simple endoscopic index for UC that takes into account the severity and distribution of mucosal inflammation. METHODS In this multicentre trial, UC patients undergoing colonoscopy were prospectively enrolled. For the Modified Score (MS), the sum of Mayo Endoscopic Subscores (MESs) for five colon segments (ascending, transverse, descending, sigmoid and rectum) was calculated. The Extended Modified Score (EMS) was obtained by multiplying the MS by the maximal extent of inflammation. The Modified Mayo Endoscopic Score (MMES) was obtained by dividing the EMS by the number of segments with active inflammation. Colon biopsies were obtained from the rectum and sigmoid, as well as from all inflamed segments, by standard methods. Clinical activity was scored according to the Partial Mayo Score (PMS). Biological activity was scored according to C-reactive protein (CRP) and faecal calprotectin (FC) levels. Histological activity was scored according to the Geboes Score (GS). RESULTS One hundred and seventy-one UC patients (38% female, median age 47 years, median disease duration 13 years) were included. The MMES correlated significantly with the PMS (r = 0.535), CRP (r = 0.238), FC (r = 0.730) and GS (r = 0.615) (all p < 0.001). Median MMES scores were significantly higher in patients with clinical, biological or histological activity (all p ≤ 0.001) CONCLUSIONS: The MMES is an easy to use endoscopic index for UC that combines the severity analysis of the MES with disease extent, and correlates very well with clinical, biological and histological disease activity.
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Affiliation(s)
- Triana Lobatón
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Talat Bessissow
- Department of Gastroenterology, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Gert De Hertogh
- Department of Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bart Lemmens
- Department of Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Chelsea Maedler
- Department of Pathology, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Gert Van Assche
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Raf Bisschops
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Paul Rutgeerts
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alain Bitton
- Department of Gastroenterology, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Waqqas Afif
- Department of Gastroenterology, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Victoria Marcus
- Department of Pathology, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Marc Ferrante
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
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136
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Theede K, Kiszka-Kanowitz M, Nordgaard-Lassen I, Mertz Nielsen A. The Impact of Endoscopic Inflammation and Mucosal Healing on Health-related Quality of Life in Ulcerative Colitis Patients. J Crohns Colitis 2015; 9:625-32. [PMID: 25956537 DOI: 10.1093/ecco-jcc/jjv081] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health-related quality of life [HRQoL] is impaired in ulcerative colitis and is correlated to clinical disease activity. The recent shift towards more objective treatment goals like mucosal healing generates a need for evaluating the association between endoscopic disease activity, mucosal healing and HRQoL. METHODS In this cross-sectional study, patients with either active or inactive ulcerative colitis underwent sigmoidoscopy. Clinical disease activity was assessed by the Simple Clinical Colitis Activity Index [SCCAI], endoscopic inflammation by the Mayo Endoscopic Subscore [MES], and HRQoL by the Short Inflammatory Bowel Disease Questionnaire [SIBDQ] and Short Health Scale [SHS]. RESULTS A total of 110 patients, 71% with active disease, had a median SCCAI score of 3 and a median MES score of 1. Patients in clinical remission had a mean SIBDQ of 60 and SHS of 6. HRQoL decreased significantly with increasing clinical (SIBDQ [χ(2) = 61.8, p < 0.0001] and SHS [χ(2) = 63.4, p < 0.0001]) and endoscopic disease activity (SIBDQ [χ(2) = 33.1, p < 0.0001] and SHS [χ(2) = 40.3, p < 0.0001]). Mucosal healing was associated with a higher HRQoL than active inflammation (59/46, p < 0.0001 [SIBDQ] and 7/20, p < 0.0001 [SHS]). Decreased HRQoL was observed with more extensive disease. Linear regression revealed strong association between SIBDQ and SHS. CONCLUSIONS Not only clinical disease activity but also endoscopic inflammation and disease extent were associated with decreased HRQoL. Patients with mucosal healing had significant higher HRQoL, emphasising the importance of this treatment goal. Both SHS and SIBDQ are easy to use and to implement, and were strongly correlated.
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Affiliation(s)
- Klaus Theede
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Denmark
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137
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Dulai PS, Levesque BG, Feagan BG, D’Haens G, Sandborn WJ. Assessment of mucosal healing in inflammatory bowel disease: review. Gastrointest Endosc 2015; 82:246-55. [PMID: 26005012 PMCID: PMC6709676 DOI: 10.1016/j.gie.2015.03.1974] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Mucosal healing is an important treatment end-point in inflammatory bowel disease, and achieving mucosal healing has been demonstrated to improve disease-related outcomes. Considerable uncertainty exists, however, regarding the optimal approach for the assessment of mucosal healing. AIMS To compare currently available diagnostic tools for the assessment of mucosal healing and outline the ideal approach to integrating these tools into clinical trials and clinical practice. METHODS Review article. RESULTS Endoscopy represents the criterion standard for the assessment of mucosal healing, and frequent endoscopic assessment is associated with a higher rate of achieving mucosal healing. The use of mucosal biopsy allows for the identification of persistent histologic disease activity, but the incremental clinical benefit of achieving histologic healing is yet to be determined. Magnetic resonance enterography has a high sensitivity for ulcer healing in endoscopically inaccessible disease activity. However, the presence of mucosal lesions cannot be reliably excluded based on this modality alone, and further small-bowel endoscopy should be considered in symptomatic patients. Video capsule endoscopy or device-assisted enteroscopy can be used, with device-assisted enteroscopy being preferred in stricturing Crohn's disease because of the risk of capsule retention or in patients in whom small-bowel malignancy is a possibility. CONCLUSIONS Endoscopy remains the criterion standard for the assessment of mucosal healing. Several alternative diagnostic modalities have become available that can be of value in specific clinical circumstances, particularly in patients with small-bowel involvement.
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Affiliation(s)
- Parambir S. Dulai
- University of California San Diego, San Diego, CA
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Barrett G. Levesque
- University of California San Diego, San Diego, CA
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Brian G. Feagan
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Geert D’Haens
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - William J. Sandborn
- University of California San Diego, San Diego, CA
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, Ontario, Canada
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Naganuma M, Hosoe N, Kanai T, Ogata H. Recent trends in diagnostic techniques for inflammatory bowel disease. Korean J Intern Med 2015; 30:271-8. [PMID: 25995657 PMCID: PMC4438281 DOI: 10.3904/kjim.2015.30.3.271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/16/2015] [Indexed: 12/16/2022] Open
Abstract
Although ileocolonoscopy is the gold standard for diagnosis of inflammatory bowel disease and is useful for assessing the disease severity in the colon and terminal ileum, several alternative diagnostic techniques have been developed recently. For ulcerative colitis (UC), magnification colonoscopy, endocytoscopy, and confocal laser endomicroscopy enable assessment of histological inflammation without the need for biopsy. Capsule endoscopy is useful for detection of small intestinal and colonic lesions in both female and male patients. For UC, capsule endoscopy may be useful for evaluating colonic inflammation in patients with a previous poor colonoscopy experience, while it should be used only in Crohn's disease (CD) patients with unexplained symptoms when other examinations are negative. Magnetic resonance enterography (MRE) is particularly useful for detecting transmural inflammation, stenosis, and extraintestinal lesions, including abscesses and fistulas. MRE is also useful when evaluating small and large intestinal lesions, even in cases with severe strictures in which full evaluation of the small bowel would be virtually impossible using other devices. Therefore, the appropriate diagnostic devices for detecting CD lesions in the small and large intestine should be used.
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Affiliation(s)
- Makoto Naganuma
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Department of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
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Bressler B, Marshall JK, Bernstein CN, Bitton A, Jones J, Leontiadis GI, Panaccione R, Steinhart AH, Tse F, Feagan B. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Gastroenterology 2015; 148:1035-1058.e3. [PMID: 25747596 DOI: 10.1053/j.gastro.2015.03.001] [Citation(s) in RCA: 267] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 02/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The medical management of ulcerative colitis (UC) has improved through the development of new therapies and novel approaches that optimize existing drugs. Previous Canadian consensus guidelines addressed the management of severe UC in the hospitalized patient. We now present consensus guidelines for the treatment of ambulatory patients with mild to severe active UC. METHODS A systematic literature search identified studies on the management of UC. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a working group of specialists. RESULTS The participants concluded that the goal of therapy is complete remission, defined as both symptomatic and endoscopic remission without corticosteroid therapy. The consensus includes 34 statements focused on 5 main drug classes: 5-aminosalicylate (5-ASA), corticosteroids, immunosuppressants, anti-tumor necrosis factor (TNF) therapies, and other therapies. Oral and rectal 5-ASA are recommended first-line therapy for mild to moderate UC, with corticosteroid therapy for those who fail to achieve remission. Patients with moderate to severe UC should undergo a course of oral corticosteroid therapy, with transition to 5-ASA, thiopurine, anti-TNF (with or without thiopurine or methotrexate), or vedolizumab maintenance therapy in those who successfully achieve symptomatic remission. For patients with corticosteroid-resistant/dependent UC, anti-TNF or vedolizumab therapy is recommended. Timely assessments of response and remission are critical to ensuring optimal outcomes. CONCLUSIONS Optimal management of UC requires careful patient assessment, evidence-based use of existing therapies, and thorough assessment to define treatment success.
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Affiliation(s)
- Brian Bressler
- Division of Gastroenterology, Department of Medicine, St Paul's Hospital, Vancouver, British Columbia.
| | - John K Marshall
- Department of Medicine, McMaster University, Hamilton, Ontario
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec
| | - Jennifer Jones
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan
| | | | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta
| | | | - Francis Tse
- Department of Medicine, McMaster University, Hamilton, Ontario
| | - Brian Feagan
- Robarts Research Institute, Western University, London, Ontario, Canada
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140
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Reinisch W, Reinink AR, Higgins PDR. Factors associated with poor outcomes in adults with newly diagnosed ulcerative colitis. Clin Gastroenterol Hepatol 2015; 13:635-42. [PMID: 24887059 DOI: 10.1016/j.cgh.2014.03.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 03/05/2014] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
Abstract
It is a challenge to accurately identify patients with early stage ulcerative colitis (UC) who are at highest risk for a poor outcome and therefore might require salvage therapy. Several epidemiologic and clinical studies have analyzed factors associated with poor prognosis and increased risk for colectomy. We review prognostic factors for adults with newly diagnosed UC and discuss which patients might benefit from rapid and progressive therapy. Patients with poor prognoses tend to be young nonsmokers with high levels of inflammatory biomarkers, low levels of hemoglobin, and extensive disease, based on colonoscopy. We examine these risk factors in 2 hypothetical patients who have been newly diagnosed with UC.
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Affiliation(s)
- Walter Reinisch
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Andrew R Reinink
- Department of Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Peter D R Higgins
- Department of Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
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141
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Schechter A, Griffiths C, Gana JC, Shaoul R, Shamir R, Shteyer E, Bdolah-Abram T, Ledder O, Turner D. Early endoscopic, laboratory and clinical predictors of poor disease course in paediatric ulcerative colitis. Gut 2015; 64:580-8. [PMID: 24848266 DOI: 10.1136/gutjnl-2014-306999] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Data to support treatment algorithms in ambulatory paediatric UC are scarce. We aimed to explore the 1 year outcome in an inception cohort of paediatric UC patients and to identify early predictors of good outcome that might serve as short term treatment targets. DESIGN A chart review of 115 children with new onset UC was performed (age 11 ± 4.1 years; 58 (50%) males; 86 (75%) extensive colitis; 70 (61%) moderate-severe disease; 63 (55%) received steroids at baseline). We assessed the Paediatric Ulcerative Colitis Activity Index (PUCAI) and laboratory variables at the time of diagnosis and at 3 months, and endoscopy at diagnosis. RESULTS The 3 month PUCAI was the strongest predictor of 1 year sustained steroid free remission (SSFR) (area under the receiver operating characteristic curve (AUROC)=0.7 (95% CI 0.6 to 0.8) and colectomy by 2 years (AUROC=0.75 (0.6 to 0.89)). SSFR was achieved in 9/54 (17%) children who had active disease (PUCAI ≥ 10) at 3 months (negative predictive value (NPV)=83%) and by 4/46 (8.6%) of those with a PUCAI score >10; (NPV=91%, positive predictive value=52%; p<0.001), implying that PUCAI >10 at 3 months has a probability of 9% for achieving SSFR versus 48% with a PUCAI value of ≤10. None of the variables at baseline was predictive of SSFR or colectomy (endoscopic severity, disease extent, age, PUCAI or C reactive protein/erythrocyte sedimentation rate/albumin/haemoglobin; all AUROC<0.6, p>0.05) but baseline PUCAI predicted subsequent acute severe colitis and the need for salvage medical therapy. CONCLUSIONS Completeness of the early response appears more important than baseline UC severity for predicting outcome in children, and supports using PUCAI<10 as a feasible treatment goal. Our data suggest that treatment escalation should be considered with a PUCAI value of ≥ 10 at 3 months.
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Affiliation(s)
| | | | - Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Chile
| | | | - Raanan Shamir
- Schneider Children's Medical Centre, Petah Tikva, Israel
| | - Eyal Shteyer
- Hadassah Medical Centre, Jerusalem, Israel The Hebrew University of Jerusalem, Israel
| | | | - Oren Ledder
- Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Dan Turner
- Shaare Zedek Medical Centre, Jerusalem, Israel The Hebrew University of Jerusalem, Israel
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Christophorou D, Funakoshi N, Duny Y, Valats JC, Bismuth M, Pineton De Chambrun G, Daures JP, Blanc P. Systematic review with meta-analysis: infliximab and immunosuppressant therapy vs. infliximab alone for active ulcerative colitis. Aliment Pharmacol Ther 2015; 41:603-12. [PMID: 25678223 DOI: 10.1111/apt.13102] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 09/29/2014] [Accepted: 01/15/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The benefit of the combination of infliximab (IFX) and immunosuppressant (IS) therapy is debated in ulcerative colitis (UC). AIMS To determine whether the combination of IFX and IS therapy is more effective than infliximab alone for active UC regardless of prior IS use. METHODS We identified all controlled trials including patients with moderate-to-severe active UC, treated by either IFX or combined IFX-IS therapy. The main outcome was clinical remission at 4-6 months. Two statistical methods were used, Mantel-Haenszel and Der-Simonian and Laird. Inter-trial heterogeneity was taken into account and publication bias was assessed. RESULTS Four controlled trials were analysed and included in the meta-analysis. These four trials included 765 patients, 389 treated with IFX alone and 376 treated with IFX and IS. At 4-6 months' therapy, the clinical remission rate was significantly lower for the IFX monotherapy group OR 0.50, 95% CI [0.34-0.73], P < 0.01 (P-heterogeneity = 0.49). The Harbord test did not show evidence of publication bias (P = 0.29). Calculation of an adjusted OR using the Duval and Tweedie method did not significantly modify results [OR 0.63, 95% CI (0.47-0.85)]. According to Orwin's formula, four additional medium-sized nonsignificant studies would be necessary to reduce the effect size to a nonsignificant value. At 12 months of therapy, there was no significant difference between the two groups: OR 0.60, 95% CI [0.17-2.06], P = 0.41 (P-heterogeneity = 0.01). CONCLUSION Combination therapy with IFX-IS is more effective than IFX alone for achieving and maintaining clinical remission at 4-6 months for patients with moderate-to-severe ulcerative colitis, regardless of prior IS use.
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Affiliation(s)
- D Christophorou
- Service d'Hépato-gastroentérologie, Hôpital Saint Eloi, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
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Ruemmele FM, Hyams JS, Otley A, Griffiths A, Kolho KL, Dias JA, Levine A, Escher JC, Taminiau J, Veres G, Colombel JF, Vermeire S, Wilson DC, Turner D. Outcome measures for clinical trials in paediatric IBD: an evidence-based, expert-driven practical statement paper of the paediatric ECCO committee. Gut 2015; 64:438-46. [PMID: 24821616 DOI: 10.1136/gutjnl-2014-307008] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Although paediatric-onset IBD is becoming more common, few medications have a registered paediatric indication. There are multiple hurdles to performing clinical trials in children, emphasising the importance of choosing an appropriate outcome measure, which can facilitate enrolment, and thereby also drug approval. The aim of this consensus statement is to highlight paediatric specific issues and key factors critical for the optimal conduct of paediatric IBD trials. DESIGN The Paediatric European Crohn's and Colitis Organisation (ECCO) committee has established an international expert panel to determine the best outcome measures in paediatric IBD, following a literature search and a modified Delphi process. All recommendations were endorsed by at least 80% agreement. RESULTS Recognising the importance of mucosal healing (MH), the panel defined steroid-free MH as primary outcome measure for all drugs of new category with one or two postintervention endoscopies per trial (at 8-12 weeks and/or 54 weeks). Since endoscopic evaluation is a barrier for recruitment in children, trials with medications already shown to induce MH in children or adults, could use paediatric-specific disease activity scores as primary outcome, including a modified Paediatric Crohn's Disease Activity Index in Crohn's disease and the Paediatric Ulcerative Colitis Activity Index in UC. Secondary outcomes should include safety issues, MR enterography-based damage and inflammatory scores (in Crohn's disease), faecal calprotectin, quality of life scales, and a patient-reported outcome. CONCLUSIONS It is crucial to perform paediatric trials early in the development of new drugs in order to reduce off-label use of IBD medication in children. The thoughtful choice of feasible and standardised outcome measures can help move us towards this goal.
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Affiliation(s)
- Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France INSERM U989, Institut IMAGINE, Paris, France APHP, Hôpital Necker Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France
| | - Jeffrey S Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Anthony Otley
- Division of Pediatric Gastroenterology, IWK Health Centre, Halifax, Canada
| | - Anne Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University, Holon, Israel
| | - Johanna C Escher
- Pediatric Gastroenterology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jan Taminiau
- Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Gabor Veres
- Ist Dept of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospital Leuven, Leuven, Belgium
| | - David C Wilson
- Department of Child Life and Health, University of Edinburgh, Scotland, UK
| | - Dan Turner
- The Juliet Keidan Institute for Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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Ho EY, Cominelli F, Katz J. Ulcerative Colitis: What is the Optimal Treatment Goal and How Do We Achieve It? ACTA ACUST UNITED AC 2015; 13:130-42. [PMID: 25619458 DOI: 10.1007/s11938-014-0044-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OPINION STATEMENT The treatment paradigms and therapeutic options for ulcerative colitis (UC) have rapidly evolved during the past decade. Traditionally, the treatment target has focused on achieving successful induction and maintenance of steroid-free clinical remission. This has been shown to provide a better quality of life and a reduction in complications, hospitalizations, and surgery. Recent studies, however, suggest that achieving "mucosal healing" or endoscopic remission may be the optimal treatment endpoint. In this review, we will examine the treatment goals for UC and the efficacy of each therapy to reach these targets. We will also review the therapeutic options available for UC: mesalamines, steroids, immunomodulators, and biologics, including the first anti-integrin inhibitor, approved in May 2014, for the treatment of UC. Therapeutic drug monitoring, which measures serum drug level and anti-drug antibody concentrations, is emerging as an important clinical decision tool in patients on tumor necrosis factor (TNF)-antagonists. These evolving treatment strategies allow gastroenterologists to optimize control of the disease and offer patients a better quality of life.
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Affiliation(s)
- Edith Y Ho
- Case Western Reserve University School of Medicine and University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA,
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145
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Kristensen V, Klepp P, Cvancarova M, Røseth A, Skar V, Moum B. Prediction of endoscopic disease activity in ulcerative colitis by two different assays for fecal calprotectin. J Crohns Colitis 2015; 9:164-9. [PMID: 25518057 DOI: 10.1093/ecco-jcc/jju015] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As mucosal healing is the goal of treatment in inflammatory bowel disease, defining a fecal [f-] calprotectin cut-off level for mucosal healing is crucial. Previous studies have presented different cut-off levels. The aim of this study was to investigate the ability of two f-calprotectin assays to differentiate mucosal healing from inflammation in ulcerative colitis. METHODS Sixty-two patients with ulcerative colitis underwent colonoscopy for classification of mucosal inflammation [Mayo endoscopic subscore]. The patients also submitted a fecal sample for f-calprotectin analysis using two different assays, Calpro ELISA and Buhlmann ELISA. RESULTS The two assays correlated significantly, with a Spearman rank correlation coefficient of 0.86. Both assays showed significantly different f-calprotectin levels in patients with a Mayo endoscopic subscore of 0 [mucosal healing] and 1–3 [inflamed mucosa] [p <0.001]. Using ROC curve analyses, we selected the best cut-off levels for both assays with responding sensitivity and specificity [presented with 95% confidence intervals]; Calpro ELISA cut-off 61 μg/g, sensitivity 84.1% [75.0–93.2%], specificity 83.3 % [74.0–92.6%], and Buhlmann ELISA cut-off 96 μg/g, sensitivity 90.9 % [83.7–98.1%], specificity 83.3 % [74.0–92.6%]. Defining mucosal healing as a Mayo endoscopic subscore ≤1, cut-off levels increased: Calpro ELISA cut-off 110 μg/g, sensitivity 80.0%[70–90%], specificity 66.6 % [54.9–78.3%]; and Buhlmann ELISA cut-off 259 μg/g, sensitivity 83.3 %[74–92.6%], specificity 71.9 % [60.7–83.1%]. CONCLUSIONS The study demonstrates the need for assay specific cut-off levels in clinical practice,as the f-calprotectin cut-off level for endoscopic disease activity differed in these two assays.
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146
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Levesque BG, Sandborn WJ, Ruel J, Feagan BG, Sands BE, Colombel JF. Converging goals of treatment of inflammatory bowel disease from clinical trials and practice. Gastroenterology 2015; 148:37-51.e1. [PMID: 25127678 DOI: 10.1053/j.gastro.2014.08.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 08/02/2014] [Accepted: 08/05/2014] [Indexed: 12/21/2022]
Abstract
It is important to have clear goals for treating inflammatory bowel disease in clinical practice and in research. Conventional end points for trials in ulcerative colitis and Crohn's disease have been based on composite indices, such as the Mayo Clinic Score and the Crohn's Disease Activity Index; these indices incorporate symptoms, signs, and findings from laboratory tests and sometimes endoscopic assessments. Although definitions of clinical response and remission have been based on these indices for regulatory purposes, they are difficult to apply to practice because they are complex and not intuitive to clinicians. This has caused a disconnect between clinical trials and practice. Recently, the use of composite indices in trials has been reevaluated in Food and Drug Administration-sponsored Gastroenterology Regulatory Endpoints and the Advancement of Therapeutics workshops due to concerns about the validity of the indices. Alternative measures of outcome and definitions of response are being developed. Patient-reported outcomes are psychometric instruments created and defined by patients to quantify symptoms. A combination of end points, comprising patient-reported outcomes and objective evaluation of inflammation by endoscopy, offers a clinically meaningful and scientifically valid alternative to existing composite indices. Unlike composite indices, response definitions based on endoscopy and patient-reported outcomes can be readily applied in practice. This convergence of outcome assessment in clinical trials and practice could expedite implementation of "treat-to-target" algorithms, in which therapy is progressively intensified until a specific treatment goal is reached. This approach could improve patient care by reducing rates of disease-related complications, surgery, and hospitalization.
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Affiliation(s)
- Barrett G Levesque
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California.
| | - Joannie Ruel
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, Department of Medicine, Western University, London, Ontario, Canada
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
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147
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Shi HY, Ng SC, Tsoi KKF, Wu JCY, Sung JJY, Chan FKL. The role of capsule endoscopy in assessing mucosal inflammation in ulcerative colitis. Expert Rev Gastroenterol Hepatol 2015; 9:47-54. [PMID: 24966092 DOI: 10.1586/17474124.2014.934359] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Assessment of mucosal inflammation is important in the management of patients with ulcerative colitis (UC). Colon capsule endoscopy (CCE) has recently been shown to be effective in colorectal polyp detection. However, its role in the evaluation of mucosal inflammation in UC is unclear. This systematic review aims to clarify the state of the art with an evidence-based summary of current studies on the utility of CCE in UC. The overall results show that the accuracy of CCE for assessment of mucosal inflammation in UC appeared to be comparable with that of colonoscopy. Long-term follow-up studies with larger sample size are needed to further validate the utility of CCE in the management of UC subjects in clinical practice.
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Affiliation(s)
- Hai Yun Shi
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, NT, HK
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148
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Louis E. Fecal calprotectin: towards a standardized use for inflammatory bowel disease management in routine practice. J Crohns Colitis 2015; 9:1-3. [PMID: 25536671 DOI: 10.1093/ecco-jcc/jju012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University Hospital of Liège, Belgium.
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149
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Nakarai A, Kato J, Hiraoka S, Inokuchi T, Takei D, Moritou Y, Akita M, Takahashi S, Hori K, Harada K, Okada H, Yamamoto K. Prognosis of ulcerative colitis differs between patients with complete and partial mucosal healing, which can be predicted from the platelet count. World J Gastroenterol 2014; 20:18367-18374. [PMID: 25561804 PMCID: PMC4277974 DOI: 10.3748/wjg.v20.i48.18367] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/11/2014] [Accepted: 07/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the difference in clinical outcome between ulcerative colitis (UC) patients with Mayo endoscopic subscore (MES) 0 and those with MES 1.
METHODS: UC patients with sustained clinical remission of 6 mo or more at the time of colonoscopy were examined for clinical outcomes and the hazard ratios of clinical relapse according to MES. Parameters, including blood tests, to identify predictive factors for MES 0 and slight endoscopic recurrence in clinically stable patients were assessed. Moreover, a receiver operating characteristic curve was generated, and the area under the curve was calculated to indicate the utility of the parameters for the division between complete and partial mucosal healing. All P values were two-sided and considered significant when less than 0.05.
RESULTS: A total of 183 patients with clinical remission were examined. Patients with MES 0 (complete mucosal healing: n = 80, 44%) were much less likely to relapse than those with MES 1 (partial mucosal healing: n = 89, 48%) (P < 0.0001, log-rank test), and the hazard ratio of risk of relapse in patients with MES 1 vs MES 0 was 8.17 (95%CI: 4.19-17.96, P < 0.0001). The platelet count (PLT) < 26 × 104/μL was an independent predictive factor for complete mucosal healing (OR = 4.1, 95%CI: 2.15-7.99). Among patients with MES 0 at the initial colonoscopy, patients of whom colonoscopy findings shifted to MES 1 showed significant increases in PLT compared to those who maintained MES 0 (3.8 × 104/μL vs -0.6 × 104/μL, P < 0.0001).
CONCLUSION: The relapse rate differed greatly between patients with complete and partial mucosal healing. A shift from complete to partial healing in clinically stable UC patients can be predicted by monitoring PLT.
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150
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Bryant RV, Winer S, Travis SPL, Riddell RH. Systematic review: histological remission in inflammatory bowel disease. Is 'complete' remission the new treatment paradigm? An IOIBD initiative. J Crohns Colitis 2014; 8:1582-97. [PMID: 25267173 DOI: 10.1016/j.crohns.2014.08.011] [Citation(s) in RCA: 219] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/06/2014] [Accepted: 08/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Advances in the medical management of inflammatory bowel disease (IBD) have altered treatment targets. Endoscopic mucosal healing is associated with better outcomes in IBD, though less is known about the significance of achieving histological remission. Our aim was to perform a systematic review to investigate whether histological or 'complete' remission constitutes a further therapeutic target in IBD. METHODS A bibliographic search was performed on the 1st of October 2013 and subsequently on the 1st of March 2014 of online databases (OVID SP MEDLINE, OVID EMBASE, National Pubmed Central Medline, Cochrane Library, ISI, conference abstracts), using MeSH terms and key words: ("inflammatory bowel diseases" OR "crohn disease" OR "ulcerative colitis" OR "colitis") AND ("mucosal healing" OR "histological healing" OR "pathological healing" OR "histological scoring" OR "pathological scoring"). RESULTS The search returned 2951 articles. 120 articles were cited in the final analysis. There is no validated definition of histological remission in IBD. There are 22 different histological scoring systems for IBD, none of which are fully validated. Microscopic inflammation persists in 16-100% of cases of endoscopically quiescent disease. There is evidence that histological remission may predict risk of complications in ulcerative colitis beyond endoscopic mucosal healing, though data are scarce in Crohn's disease. CONCLUSIONS Histological remission in IBD represents a target distinct from endoscopic mucosal healing, not yet routinely sought in clinical trials or practice. There remains a need for a standardized and validated histological scoring system and to confirm the prognostic value of histological remission as a treatment target in IBD.
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Affiliation(s)
- R V Bryant
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, United Kingdom
| | - S Winer
- Department of Pathology and Laboratory Medicine, Mt Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - S P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, United Kingdom
| | - R H Riddell
- Department of Pathology and Laboratory Medicine, Mt Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada.
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