Inducing remission of ulcerative colitis: are clinicians better equipped than ever?

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Date: Feb. 2013
Publisher: Expert Reviews Ltd.
Document Type: Report
Length: 2,258 words
Lexile Measure: 1510L

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Author(s): Alessandro Armuzzi 1 , Carla Felice 2

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anti-TNFa; clinical remission; corticosteroids; cyclosporine; healing; histological thiopurines; mesalazine; mucosal healing; ulcerative colitis

The clinical course of ulcerative colitis (UC), a chronic inflammatory bowel disease, may be different in each patient. Data reported from a recent population-based inception cohort show that a high percentage of cases (55%) have spontaneous remission or mild severity of clinical symptoms after initial high activity. Other situations include 37% of patients who present chronic intermittent severe symptoms, 6% of subjects with chronically active disease and those who have an increase of symptom severity after an initial prolonged low activity (1%) [1] . In all these cases, we need medical therapies to induce and try to maintain remission. The correct choice of therapy should also be influenced by extension of disease, considering that at diagnosis approximately 60% of patients present left-sided disease, but nearly 15% and up to 30% of them may have an involvement of more proximal segments of colon over time [1] .

The definition of remission, as a therapeutic target, is not universally validated and has been evolving over the last years. The resolution of intestinal symptoms (i.e., bloody diarrhea and abdominal pain) was initially the principal aim of medical therapies. More recently, the role of endoscopic and histological healing has emerged as a significant predictive factor of long-term clinical remission [2] . Thus, a new definition of 'deep remission', including clinical, endoscopic and histological findings, should be considered as the therapeutic goal.

Surgery still has an important role in the management of acute severe colitis, refractory to salvage treatments and chronically active, moderate-to-severe colitis. A recent comparison among three population-based cohorts of inflammatory bowel disease patients from Denmark, including 1575 UC subjects, showed rates of colectomy between 6 and 11% during the first year after diagnosis and a 10-year probability of colectomy of 24% calculated from cohorts 1 and 2 (observation time: 1962-2003 [3] ). The IBSEN study reported a cumulative colectomy rate of 9.8% (95% CI: 7.4-12.4%) after 10 years of disease [1] . These data demonstrate that we have not yet found the perfect medical therapy, or that we have not completely understood how to use drugs that are available so far.

The therapy of UC is mainly based on 5-aminosalicylates, corticosteroids, immunosuppressants (i.e., thiopurines, cyclosporine) and biological agents (i.e., anti-TNF[alpha] antibodies, such as infliximab and adalimumab).

The efficacy and safety of mesalazine (5-ASA) in inducing and maintaining clinical remission in mild-to-moderate UC has been confirmed in two recent Cochrane reviews [4,5] , in particular when 5-ASA was compared with placebo. Depending on extension and activity of disease, the possibility to use several formulations of oral or topical 5-ASA is a benefit. A recent meta-analysis comparing different formulations of 5-ASA highlighted the superiority of combined therapy (topical and oral) in comparison with just oral 5-ASA in inducing clinical remission of mild-to-moderate UC [6] .

The role of corticosteroids as systemic or topical treatment in specific stages of moderate-to-severe UC remains confirmed by international guidelines [7] . Percentages of partial or...

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Gale Document Number: GALE|A316900817