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Mitrev N, Kariyawasam V. Treatment endpoints in ulcerative colitis: Does one size fit all? World J Gastrointest Pharmacol Ther 2024; 15:91591. [DOI: 10.4292/wjgpt.v15.i2.91591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/28/2024] [Accepted: 04/10/2024] [Indexed: 04/24/2024] Open
Abstract
A treat-to-target strategy in inflammatory bowel disease (IBD) involves treatment intensification in order to achieve a pre-determined endpoint. Such uniform and tight disease control has been demonstrated to improve clinical outcomes compared to treatment driven by a clinician’s subjective assessment of symptoms. However, choice of treatment endpoints remains a challenge in management of IBD via a treat-to-target strategy. The treatment endpoints for ulcerative colitis (UC), recommended by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) consensus have changed somewhat over time. The latest STRIDE-II consensus advises immediate (clinical response), intermediate (clinical remission and biochemical normalisation) and long-term treatment (endoscopic healing, absence of disability and normalisation of health-related quality of life, as well as normal growth in children) endpoints in UC. However, achieving deeper levels of remission, such as histologic normalisation or healing of the gut barrier function, may further improve outcomes among UC patients. Generally, all medical therapy should seek to improve short- and long-term mortality and morbidity. Hence treatment endpoints should be chosen based on their ability to predict for improvement in short- and long-term mortality and morbidity. Potential benefits of treatment intensification need to be weighed against the potential harms within an individual patient. In addition, changing therapy that has achieved partial response may lead to worse outcomes, with failure to recapture response on treatment reversion. Patients may also place different emphasis on certain potential benefits and harms of various treatments than clinicians, or may have strong opinions re certain therapies. Potential benefits and harms of therapies, incremental benefits of achieving deeper levels of remission, as well as uncertainties of the same, need to be discussed with individual patients, and a treatment endpoint agreed upon with the clinician. Future research should focus on quantifying the incremental benefits and risks of achieving deeper levels of remission, such that clinicians and patients can make an informed decision about appropriate treatment end-point on an individual basis.
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Affiliation(s)
- Nikola Mitrev
- Department of Gastroenterology, Blacktown Hospital, Blacktown 2148, NSW, Australia
- Blacktown/Mt Druitt Clinical School, University of Western Sydney, Blacktown 2148, NSW, Australia
- Department of Gastroenterology, Wollongong Hospital, Loftus St, Wollongong 2500, NSW, Australia
| | - Viraj Kariyawasam
- Department of Gastroenterology, Blacktown Hospital, Blacktown 2148, NSW, Australia
- Blacktown/Mt Druitt Clinical School, University of Western Sydney, Blacktown 2148, NSW, Australia
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Yurdaydin C, Abbas Z, Buti M, Cornberg M, Esteban R, Etzion O, Gane EJ, Gish RG, Glenn JS, Hamid S, Heller T, Koh C, Lampertico P, Lurie Y, Manns M, Parana R, Rizzetto M, Urban S, Wedemeyer H. Treating chronic hepatitis delta: The need for surrogate markers of treatment efficacy. J Hepatol 2019; 70:1008-1015. [PMID: 30982526 DOI: 10.1016/j.jhep.2018.12.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
Chronic hepatitis delta represents the most severe form of chronic viral hepatitis. The current treatment of hepatitis delta virus (HDV) infection consists of the use of interferons and is largely unsatisfactory. Several new compounds are currently in development for the treatment of HDV infection. However, surrogate markers that can be used to develop clinical endpoints in HDV infection are not well defined. In the current manuscript, we aimed to evaluate the existing data on treatment of HDV infection and to suggest treatment goals (possible "trial endpoints") that could be used across different clinical trials.
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Affiliation(s)
- Cihan Yurdaydin
- Department of Gastroenterology, Ankara University, Ankara, and Department of Internal Medicine, Koc University, Istanbul, Turkey.
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Maria Buti
- Liver Unit, Hospital Universitario Vall d'Hebron and Ciber-ehd, Instituto Carlos III, Barcelona, Spain
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Rafael Esteban
- Liver Unit, Hospital Universitario Vall d'Hebron and Ciber-ehd, Instituto Carlos III, Barcelona, Spain
| | - Ohad Etzion
- Institute of Gastroenterology and Liver Diseases Soroka University Medical Center Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | | | - Robert G Gish
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Jeffrey S Glenn
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Saeed Hamid
- Aga Khan University Hospital, Department of Medicine, Karachi, Pakistan
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Pietro Lampertico
- CRC "A. M. e A. Migliavacca", Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Yoav Lurie
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621 Ramat Gan, Israel
| | - Michael Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Raymundo Parana
- Hepatology Centre of the University Hospital Professor Edgar Santos, Federal University of Bahia, Salvador, Brazil
| | - Mario Rizzetto
- Department of Gastroenterology, University of Turin, Turin, Italy
| | - Stephan Urban
- Department of Infectious Diseases, Molecular Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
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Frey MK, Philips SR, Jeffries J, Herzberg AJ, Harding-Peets GL, Gordon JK, Bajada L, Ellis AE, Blank SV. A qualitative study of ovarian cancer survivors' perceptions of endpoints and goals of care. Gynecol Oncol 2014; 135:261-5. [PMID: 25230215 DOI: 10.1016/j.ygyno.2014.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 09/02/2014] [Accepted: 09/06/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A survey of the Ovarian Cancer National Alliance revealed a communication gap between physicians and survivors. This qualitative study explored the space between perceptions in hopes of better defining treatment endpoints meaningful to treating physicians and their patients. METHODS A focus group of ovarian cancer survivors (n=22) was assembled via the survivor support network SHARE. A physician-guided session explored expectations of treatment, perceived outcomes, toxicity thresholds and decision making. The session was recorded, transcribed and coded. Common themes were identified and used to perform intra-case analysis by two independent reviewers. RESULTS The main themes identified were barriers to communication, importance of frequent communication between patient and physician regarding goals, and expectations of treatment changing with position along the treatment continuum. One hundred percent of participants identified communication with their physician as an essential element in determining treatment course. However, only 14% reported having a discussion about goals, values and perceptions with their physician preceding treatment decisions. Participants reported that the terms progression free and overall survival held minimal significance for them and instead they preferred an individualized approach to care focusing on quality of life. Many women underreported side effects with reasons ranging from fear of dose reductions and additional tests to forgetting about symptoms due to anxiety. CONCLUSIONS An objective measure of treatment success meaningful to survivors, physicians and regulators is, at present, elusive and may not exist. Ideally, future trial design would place equal weight on quantitative and qualitative measures and include information about goals of treatment.
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