Optimizing Outcomes in Ulcerative Colitis Part IV

Published Online: Thursday, December 1, 2011

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To discuss the latest developments in detection and management of UC, we interviewed three of the country’s leading UC specialists: Raymond K. Cross, MD, associate professor of medicine and director of the Inflammatory Bowel Disease Program at the University of Maryland School of Medicine; Asher A. Kornbluth, MD, clinical professor of medicine at Mount Sinai School of Medicine; and William J. Sandborn, MD, chief of the division of gastroenterology at the University of California, San Diego.

Should Physicians Aim for Mucosal Healing?
Therapy for UC has traditionally focused on improving symptoms, with the goal of achieving symptomatic remission. However, mucosal healing has recently emerged as an important predictor of long-term outcomes such as need for future colectomy.¹ Despite recent data supporting mucosal healing as a therapeutic end point, it has not been widely accepted by physicians. “We are grappling with that,” said Cross. “If you don’t achieve those goals, the risk of flaring in the future is higher.” He also suggested that using the mucosa as the end point would be likely to increase the chance that patients would be exposed to combinations of drugs, introducing more risks, such as opportunistic infections.
 
“We have good data showing patients achieve mucosal healing with infliximab, and this patient population is more likely to have reduced rates of hospitalization and, more importantly, reduced rates of colectomy,” said Kornbluth, adding that other studies suggest that other agents can also achieve mucosal healing.^2,3 “There is also good evidence from multiple centers, both in the United States and Europe, that reducing inflammation longterm is likely to lead to reduction in the development of dysplasia and colorectal cancer in patients with ulcerative colitis.”
 
In Sandborn’s opinion, mucosal healing as the primary end point should and will be the norm in future trials and guidelines. “The disease is really the underlying inflammation, and you measure that with colonoscopy,” he said. “We are increasingly seeing that patients that you bring to complete mucosal healing have considerably higher rates of steroid-free remission.”
 
Conclusion
Accurate and timely diagnosis is crucial for positive outcomes for patients with UC. Physicians need to rule out enteric infections and monitor the presence of C. difficile during any flare-up, said Kornbluth. “I think it is very important to recognize that maintenance of remission is an extremely important facet of treatment,” he said, adding that patients need to have a complete remission before tapering down to maintenance therapy. “I think it is imperative that patients are not maintained on long-term steroids, and physicians need to recognize the great value of infliximab in the management of these patients and not just use it as a last-ditch attempt in the very sickest patients.”
 
References
1. Lichtenstein GR, Rutgeerts P. Importance of mucosal healing in ulcerative colitis. Inflamm Bowel Dis. 2010;16(2):338-346.
2. Lichtenstein GR. Effect of once- or twice-daily MMX mesalamine (SPD476) for the induction of remission of mild to moderately active ulcerative colitis. Clin Gastroenterol Hepatol. 2007;5(1):95-102.
3. Kruis W, Kiudelis G, Rácz I, et al. Once daily versus three times daily mesalazine granules in active ulcerative colitis: a double-blind, double-dummy, randomised, non-inferiority trial. Gut. 2009;58(2):233-240.

We want to hear your opinion on ulcerative colitis treatment:
Do you think mucosal healing should be the goal of ulcerative colitis treatment? Why or why not?