Enhanced Treatment Endpoints Leads to Lower Risk of Ulcerative Colitis Relapse

By increasing the threshold of what meets a clinical endpoint, researchers could ultimately reduce the risk of relapse for patients with ulcerative colitis (UC).

A team, led by Hyuk Yoon, Division of Gastroenterology, University of California San Diego, examined whether incorporating more rigorous remission definitions for endoscopic and histologic remission impacts the risk of relapse of ulcerative colitis.

The investigators conducted a systematic review of available literature to identify cohort studies in adults with ulcerative colitis in clinical remission that reported a minimum of a 12-motnh risk of clinical relapse based on the Mayo endoscopy subscore (0 vs. 1) and/or histologic disease activity, in patients with endoscopic remission.

The team used random effects meta-analysis to calculate relative and absolute risk of clinical relapse in patients with ulcerative colitis achieving different treatment targets.

Ultimately, the investigators included 17 studies involving 2608 ulcerative colitis patients in clinical remission in the meta-analysis.

The investigators found patients achieving a MES 0 had a 52% lower risk of clinical relapse (RR, 0.48; 95% CI, 0.37-0.62) compared to patients achieving a MES 1.

The median 12-month risk of clinical relapse in patients with MES 1 was 28.7%, while the estimated annual risk of clinical relapse in patients with a MES 0 was 13.7% (95% CI, 10.6-17.9).

The investigators looked at 10 studies in the meta-analysis involving patients in endoscopic remission (MES 0), finding that patients who achieved histologic remission had a 63% lower risk of clinical relapse when compared to patients with persistent histologic activity (RR, 0.37; 95% CI, 0.24-0.56).

The estimated annual risk of clinical relapse in patients who achieved histologic remission was 5.0 % (95% CI, 3.3-7.7).

“In a systematic review and meta-analysis of patients with UC in clinical remission, we observed that patients achieving more rigorous treatment endpoints (endoscopic and histologic remission) have a substantially lower risk of clinical relapse compared with patients achieving clinical remission,” the authors wrote.

Recently, the American Gastroenterology Association (AGA) released a new set of recommendations for patients with ulcerative colitis.

A team, led by Joseph D. Feuerstein, MD, Division of Gastroenterology and Center for Inflammatory Bowel Diseases at Beth Israel Deaconess Medical Center, recently released new ulcerative colitis guidelines on behalf of the AGA that address the adult outpatients with moderate to severe ulcerative colitis, as well as the medical management of adult hospitalized patients.

The guideline focuses on immunomodulators, biologics, and small molecules for induction and maintenance of remission for moderate to severe ulcerative colitis and decreasing the risk of colectomy patients with acute severe ulcerative colitis.

The authors strongly suggest adult outpatients with moderate to severe UC, the AGA recommends using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment.

Also, adult outpatients with moderate to severe ulcerative colitis who are naïve to biologic agents should use infliximab or vedolizumab rather than adalimumab, for induction of remission and tofacitinib should only be used in the setting of a clinical or registry study.

The study, “Incremental Benefit of Achieving Endoscopic and Histologic Remission in Patients with Ulcerative Colitis: A Systematic Review and Meta-Analysis,” was published online in Gastroenterology.