Lack of mucosal healing, based on endoscopic analysis, identifies patients with ulcerative colitis (UC) who are not likely to respond to corticosteroid therapy, according to Sandro Ardizzone et al. in the June issue of Clinical Gastroenterology and Hepatology.
In a prospective study, Ardizzone et al. followed 157 patients with moderate to severe UC who required steroid therapy within 12 months of diagnosis; all patients received clinical and endoscopic evaluations after 5 years. The authors assessed the patients for clinical response (reduced symptoms and physical signs) and endoscopic response (healing of the lining of the colon, determined by endoscopy); they compared these with relapse rates and need for immunosuppressive therapies, surgery (colectomy), or hospitalization.
They found that lack of mucosal healing was the only factor associated with negative outcome. Over the 5-year study period, Ardizzone et al. observed that patients who had both a clinical and endoscopic response had lower rates of hospitalization than patients with only clinical response (25% vs 48.7%). They also found significant differences between groups in requirement for additional immunosuppressive therapy (5% of patients with both responses vs 25.6% of patients with only a clinical response) or colectomy (3.3% of patients with both responses vs 18.0% of those with only a clinical response).
Failure to achieve endoscopic remission after a first course of steroids is common, but Ardizzone et al. show that it predicts a more aggressive course of disease. They conclude that monitoring endoscopic response could be a more accurate prognostic tool than clinical response alone, and that it is time for us to treat to endoscopic remission as a primary objective of therapy.
The study is unique in that it analyzed long-term clinical and endoscopic outcomes of patients with UC who all received corticosteroid therapy within a year of diagnosis; previous studies have not associated endoscopic observations with the subsequent course of the disease in a homogenous population.
Interestingly, the authors observed that women had greater clinical and endoscopic responses to corticosteroid treatment than men. Sex-related differences in disease follow-up evaluation, hormonal factors and drug metabolism require further study.
In an accompanying editorial, David Rubin points out that although this study adds to our appreciation of the beneﬁts of a healed mucosa in patients with UC, it does not help us know how to get there—this and other studies tell us it is not even possible for many patients.
More Information on Ulcerative Colitis:
Read the article online.
Ardizzone S, Cassinotti A, Duca P. et al. Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis. Clin Gastroenterol and Hepatol 2011;9:483–489.e3.
Read the accompanying editorial.
Rubin DT. We once were blind and now we see: is it time to treat ulcerative colitis to achieve mucosal healing?. Clin Gastroenterol and Hepatol 2011;9:456–457.