Factors associated with the achievement of mucosal healing in Crohn's disease: the benefit of endoscopic monitoring in treating to target

Benefits and Challenges of Treat-to-Target in Inflammatory Bowel Disease

There is notable disparity between symptomatology and disease activity in a significant proportion of patients with inflammatory bowel disease (IBD), and escalation of treatment based on symptoms alone can fail to significantly alter the course of disease. The STRIDE-II position statement, published in 2021 by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organisation for the Study of IBD (IOIBD) provides the most current recommendations for a treat-to-target (T2T) approach in IBD. Despite the benefits offered by a T2T approach in IBD, there are numerous drawbacks and current limitations to its widespread implementation in real-world clinical practice. Owing to the lack of a standardised definition of MH, outcome data are heterogeneous and limit the comparability of existing data. Further, studies investigating the likelihood of achieving MH with a T2T approach are limited and largely retrospective. Evidence of the real-world feasibility of tight monitoring is currently minimal and demonstrates sub-optimal adherence among patients. Further, the few studies on the acceptability and uptake of a T2T approach in real-world practice demonstrate the need for increased acceptability on both patients' and clinicians' behalf. Real-world applicability is further limited by the need for repeated endoscopic assessments of MH as well as a lack of guidance on how to incorporate the various treatment targets into therapeutic decision-making. We aim to review the benefits and challenges of the T2T approach and to discuss potential solutions to further patient care.

Predicting Mucosal Healing in Crohn's Disease: A Nomogram Model Developed from a Retrospective Cohort

Purpose

Mucosal healing (MH) has become a therapeutic end point for Crohn's disease (CD). The purpose of this study was to identify potential risk factors responsible for a lower probability of mucosal healing in CD. It also aimed to create and validate a noninvasive tool for predicting mucosal healing in CD to aid clinical decision-making.

Patients and Methods

We established a derivation cohort diagnosed with CD, in which endoscopic examination was performed before and after treatment at the First Affiliated Hospital of Nanjing Medical University between January 2010 and June 2021. Patient data including demographic and clinical characteristics and treatment details were collected. The achievement of mucosal healing (without ulceration on endoscopic examination) after treatment was the endpoint observed during follow-up. We performed logistic regression analysis to identify factors associated with mucosal healing. These factors were used to develop a model (CD mucosal healing prediction nomogram) to predict mucosal healing in CD. External validation was performed using a new cohort of 60 patients from the Second Affiliated Hospital of Soochow University between January 2012 and June 2021.

Results

A total of 331 patients were included in the derivation cohort. We found the following factors to be independently associated with mucosal healing after treatment: disease course <11 months, ulcer size <0.5 cm, Harvey-Bradshaw Index score <9, infliximab treatment, and non-exclusive use of 5-aminosalicylic acid. The model incorporating these factors achieved good discrimination, calibration, and clinical decision curve analysis results on internal validation (C-index: 0.788, 95% confidence interval [CI]: 0.74-0.84). The external validation cohort also demonstrated good discrimination (C-index: 0.785, 95% CI: 0.68-0.90) and calibration.

Conclusion

The CD mucosal healing prediction nomogram model demonstrated good reliability and validated. It can potentially be developed into a simple and clinically useful tool for predicting mucosal healing in CD.

Combination of serological biomarkers and clinical features to predict mucosal healing in Crohn's disease: a multicenter cohort study

PURPOSE

Mucosal healing (MH) has become the treatment goal of patients with Crohn's disease (CD). This study aims to develop a noninvasive and reliable clinical tool for individual evaluation of mucosal healing in patients with Crohn's disease.

METHODS

A multicenter retrospective cohort was established. Clinical and serological variables were collected. Separate risk factors were incorporated into a binary logistic regression model. A primary model and a simple model were established, respectively. The model performance was evaluated with C-index, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. Internal validation was performed in patients with small intestinal lesions.

RESULTS

A total of 348 consecutive patients diagnosed with CD who underwent endoscopic examination and review after treatment from January 2010 to June 2021 were composed in the derivation cohort, and 112 patients with small intestinal lesions were included in the validation cohort. The following variables were independently associated with the MH and were subsequently included into the primary prediction model: PLR (platelet to lymphocyte ratio), CAR (C-reactive protein to albumin ratio), ESR (erythrocyte sedimentation rate), HBI (Harvey-Bradshaw Index) score and infliximab treatment. The simple model only included factors of PLR, CAR and ESR. The primary model performed better than the simple one in C-index (87.5% vs. 83.0%, p = 0.004). There was no statistical significance between these two models in sensitivity (70.43% vs. 62.61%, p = 0.467), specificity (87.12% vs. 80.69%, p = 0.448), PPV (72.97% vs. 61.54%, p = 0.292), NPV (85.65% vs. 81.39%, p = 0.614), and accuracy (81.61% vs. 74.71%, p = 0.303). The primary model had good calibration and high levels of explained variation and discrimination in validation cohort.

CONCLUSIONS

This model can be used to predict MH in post-treatment patients with CD. It can also be used as an indication of endoscopic surveillance to evaluate mucosal healing in patients with CD after treatment.

Shooting for the Stars: Review of the STARDUST Trial and the Treat-to-Target Approach for Crohn's Disease

Crohn's disease (CD) and ulcerative colitis, collectively termed inflammatory bowel disease, are progressive autoimmune conditions of the gastrointestinal tract. Mucosal healing has been associated with fewer major abdominal surgeries and hospitalizations in patients with CD compared with patients with CD but without mucosal healing. Therefore, a treat-to-target (T2T) management approach to escalate treatment by targeting objective markers of inflammation rather than clinical symptoms alone has been introduced in recent years. The STARDUST trial is the first T2T randomized trial of adult patients with CD using endoscopy and biomarkers for dose adjustment of ustekinumab. Patients with active CD were randomized to 2 arms: T2T and standard of care (SoC). In the T2T arm, changes in dosing interval were based on endoscopic severity, clinical symptoms, and biomarkers, whereas in the SoC arm, dosing adjustments were made based on clinical symptoms alone. The primary endpoint was 50% or greater improvement in Simple Endoscopic Score for Crohn's Disease at week 48. The results of the primary endpoint found increased endoscopic response in the T2T arm compared with the SoC arm. However, the endpoint was not statistically significant using nonresponder imputation analyses. This article discusses the details and limitations of the STARDUST trial and addresses further questions regarding T2T approaches for CD.

Normalization of C-Reactive Protein Predicts Better Outcome in Patients With Crohn's Disease With Mucosal Healing and Deep Remission

Therapeutic targets for Crohn's disease (CD) have evolved from clinical and biological remission to mucosal healing (MH) and deep remission (DR). MH is defined as disappearance of ulceration, whereas DR is defined as a combination of clinical remission and MH. Limited data are available regarding differences in long-term outcomes of these patients reaching these targets. We thus aimed to evaluate patients' long-term clinical outcomes using different composite remission parameters.

Evaluation of the modified Crohn's disease activity index in patients with Crohn disease with enterostomy: A single-center observational study

ABSTRACT

Although the Crohn's Disease Activity Index (CDAI) is often used to evaluate the disease activity in Crohn's disease (CD), the number of liquid or soft stools cannot be precisely evaluated, and thus accurate scores cannot be calculated, in patients with enterostomy. Therefore, we created the modified CDAI (mCDAI), without the defecation frequency item from the CDAI, and examined its usefulness.Study participants comprised 9 patients with CD with enterostomy and 20 patients with CD without enterostomy. Correlations between the mCDAI and serum albumin (Alb) levels or C-reactive protein (CRP) levels were examined using regression analysis. Additionally, regression analyses were conducted in patients with CD without enterostomy to determine the Alb and CRP levels corresponding to the CDAI at its cutoff value for remission status (150). The obtained values were applied to the mCDAI regression equations to determine the equivalent mCDAI cutoff value.mCDAI and Alb levels were significantly negatively correlated (P < .0001). The mCDAI had a significant positive correlation with the CRP level and erythrocyte sedimentation rate (P = .0061 and P = .0133, respectively). From the regression analysis of patients with CD without enterostomy, the Alb and CRP levels equivalent to a CDAI of 150 were 3.85 g/dL and 0.62 mg/dL, respectively. When applying these values to the mCDAI regression formulas, the values of 113.8 and 115.2, respectively, were obtained. Thus, the cutoff value of the mCDAI indicating disease activity was estimated as 115.The mCDAI fully reflects the nutritional status and inflammatory response, and is convenient and useful for assessing disease activity over time, in patients with CD with enterostomy. A mCDAI score ≥ 115 indicates disease activity.

How Do We Treat Inflammatory Bowel Diseases to Aim For Endoscopic Remission?

Crohn's disease and ulcerative colitis are heterogeneous conditions which may manifest with 1 or more of a constellation of abnormal symptoms, elevated biomarkers, and/or objective evidence of inflammation on endoscopic or cross-sectional evaluation. Whilst resolution of symptoms and restoration of quality of life is the primary goal for patients following a disease flare, there may be discordance between resolution of symptoms, biomarkers, and endoscopy. Increased emphasis is placed on the achievement of endoscopic remission, given it is associated with improved outcomes and reduction in hospitalization and surgeries. As the therapeutic armamentarium for inflammatory bowel disease does not achieve remission in all patients, there is greater emphasis on repetitive interval-based assessment of disease activity with sequential algorithmic treatment adjustments until endoscopic remission is achieved, in a so-called treat-to-target approach. We review the role of symptoms, biomarkers, imaging and endoscopy within treat-to-target algorithms and provide a practical guidance to their use in clinical practice.

Variation in Care in the Management of Children With Crohn's Disease: Data From a Multicenter Inception Cohort Study

BACKGROUND

Variation in care is common in medical practice. Reducing variation in care is shown to improve quality and increase favorable outcomes in chronic diseases. We sought to identify factors associated with variation in care in children with newly diagnosed Crohn's disease (CD).

METHODS

Prospectively collected data from a 28-site multicenter inception CD cohort were analyzed for variations in diagnostic modalities, treatment, and follow-up monitoring practices, along with complicated disease outcomes over 3 years in 1046 children. Generalized linear mixed effects models were used to investigate the intercenter variations in each outcome variable.

RESULTS

The mean age at diagnosis was 12 years, and 25.9% were nonwhite. The number of participants ranged from 5 to 112 per site. No variation existed in the initial diagnostic approach. When medication exposure was analyzed, steroid exposure varied from 28.6% to 96.9% (P < 0.01) within 90 days, but variation was not significant over a 3-year period (P = 0.13). Early anti-tumor necrosis factor (anti-TNF) exposure (within 90 days) varied from 2.1% to 65.7% (P < 0.01), but variation was not significant over a 3-year period (P > 0.99). Use of immunomodulators (IMs) varied among centers both within 90 days (P < 0.01) and during 3 years of follow-up (P < 0.01). A significant variation was seen at the geographic level with follow-up small bowel imaging and colonoscopy surveillance after initial therapy.

CONCLUSIONS

Intercenter variation in care was seen with the initial use of steroids and anti-TNF, but there was no difference in total 3-year exposure to these drugs. Variation in the initiation and long-term use of IMs was significant among sites, but further research with objective measures is needed to explain this variation of care. Small bowel imaging or repeat colonoscopy in CD patients was not uniformly performed across sites. As our data show the widespread existence of variation in care and disease monitoring at geographic levels among pediatric CD patients, future implementation of various practice strategies may help reduce the variation in care.