An overview of a presentation by Professor Walter Reinisch from the Medical University of Vienna, Austria, at the Raising Expectations in Gastroenterology symposium, 2011.

Biologic treatments for ulcerative colitis are typically reserved for very severe disease and when surgery is being considered. However, clinical trial data suggests that treatment of moderately-severe disease could also be advocated.

Like Crohn's disease, ulcerative colitis should be regarded as a progressive disease – extension of disease occurs in approximately one-third of patients after 10 years. Patients at risk include those with early-onset illness, refractory disease or frequent relapses.

The rate of colectomy is approximately 10% after 10 years of disease. While this is an improvement from historical rates, there is scope to further reduce the need for surgery which is associated with postoperative complications in 25–35% of cases.

Aim for mucosal healing

Goals for treatment of ulcerative colitis have evolved over time with the emphasis now shifting to mucosal healing. There is considerable evidence for the benefits of mucosal healing in ulcerative colitis:

  • In an observational cohort pre-dating the use of biologic therapies, mucosal healing (endoscopic score 0 or 1) was associated with a significant reduction in the risk of colectomy (p<0.02)1
  • A 5-year study of newly-diagnosed patients found that early response to steroids, including mucosal healing, was associated with a reduced risk of relapse, hospitalisation, immunosuppressant use and colectomy2
  • In a cohort of patients treated with infliximab, colectomy-free survival was significantly extended in those with mucosal healing compared to those without healing (p=0.027)3
  • Subgroup analyses of the ACT studies of infliximab found that mucosal healing by week 8 was associated with increases in symptomatic and steroid-free remission at weeks 30 and 54, colectomy-free survival and time to colectomy in those with moderately to severely-active ulcerative colitis4

Though treatment is generally reserved for patients with more severe disease, the rate of response, remission and mucosal healing is greater in those with only moderately-severe disease.5

Summary

  • Ulcerative colitis should be considered a progressive disease
  • Mucosal healing can impact outcomes, including need for colectomy
  • An accelerated step-up approach may be required in non-responders
  • Biologic therapy should be advocated in patients with moderately-severe colitis

Please note, the views expressed in this article are not necessarily those of the sponsor.

References

  1. Frøslie KF et al. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology 2007; 133: 412–422.
  2. Ardizzone S et al. Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis. Clinical Gastroenterology and Hepatology 2011; 9: 483-489.
  3. Ferrante M et al. Long-term outcome after infliximab for refractory ulcerative colitis. Journal of Crohn’s & Colitis 2008; 2: 219–225.
  4. Colombel JF et al. Mucosal healing in patients with ulcerative colitis
  5. associates with a reduced colectomy risk, high incidence of symptomatic remission and corticosteroid-free state. Abstract. Gut 2010; 59 (supplement III): A411.
  6. Seow CH et al. Trough serum infliximab: a predictive factor of clinical outcome for infliximab treatment in acute ulcerative colitis. Gut 2010; 59: 49–54.

PBS information: This product is listed as a Section 100 item for Crohn’s disease and ulcerative colitis. Refer to PBS Schedule for full authority information.

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