IBD: Remission Rates Achievable by Current Therapies
IBD: Remission Rates Achievable by Current Therapies
Background New medical therapies have improved outlook in inflammatory bowel disease but published impact on surgical rates has been modest suggesting that many patients are still not attaining remission.
Aim To review remission rates with current medical treatments for inflammatory bowel disease.
Methods We searched MEDLINE (source PUBMED, 1966 to January, 2011).
Results Induction and maintenance of remission was observed in 20% (range, 9–29.5%) and 53% (range, 36.8–59.6%) of ulcerative colitis (UC) patients treated with oral 5-ASA derivatives. Induction of remission was noted in 52% (range, 48–58%) of Crohn's disease (CD) patients and 54% of UC patients treated with steroids in population-based cohorts. Maintenance of remission was reported in 71% (range, 56–95%) of CD patients on azathioprine over a 6-month to 2-year period and in 60% (range, 41.7–82.4%) in UC at 1 year or longer. Induction and maintenance of remission was noted in 39% (range, 19.3–66.7%) and 70% (range, 39–90%) of CD patients on methotrexate over a 40-week period. Induction of remission was reported in 32% (range, 25–48%), 26% (range, 18–36%) and 20% (range, 19–23%) of CD patients on infliximab, adalimumab or certolizumab pegol, respectively. The corresponding figures were 45% (range, 39–59%), 43% (range, 40–47%) and 47.9% at weeks 20–30 among initial responders. Induction of remission was observed in 33% (range, 27.5–38.8%) and 18.5% of UC patients on infliximab or adalimumab, respectively. Maintenance of remission was noted in 33% (range, 25.6–36.9%) of UC patients on infliximab at week 30. Approximately one-fifth of CD and UC patients treated with biologicals require intestinal resection after 2–5 years in referral-centre studies.
Conclusion In the era of biologics, the proportion of patients with inflammatory bowel disease not entering remission remains high.
The management of failed medical treatment for inflammatory bowel diseases (IBD) remains a challenge. Failed medical treatment can be defined as primary nonresponse or loss of response (absence of remission) in primary responders to a given drug regimen. Drug intolerance leading to drug discontinuation should be also part of the definition of failure. The ultimate goal should be remission.
In clinical practice the first step is to rule out symptoms not related to disease activity and intestinal inflammation. Notably, exclusion of mechanical problems (stricture, fistula, short bowel), undiagnosed infection (from abscesses to enteric infections, Clostridium difficile, parasites or tuberculosis); the assessment of malnutrition should be part of the management of failed medical treatment. Loss of response should be confirmed by using serum (C-reactive protein) and faecal (calprotectin, lactoferrin) markers, as well as radiological (ultrasound, computed tomography, magnetic resonance imaging) and/or endoscopic evaluation. The therapeutic armentarium for IBD mainly comprises 5-aminosalicylates (5-ASA), steroids, ciclosporin, thiopurines, methotrexate, antitumour necrosis agents, (anti-TNF) agents and in the United States (US), natalizumab. In 2011, a step-up approach is recommended for most patients with IBD. In case of failure of medical treatments, surgery should be considered.
In this review we summarise available data remission for each drug class with a focus on results from randomised, controlled trials. We will then review the need for surgery in IBD in the era of biological agents.
Abstract and Introduction
Abstract
Background New medical therapies have improved outlook in inflammatory bowel disease but published impact on surgical rates has been modest suggesting that many patients are still not attaining remission.
Aim To review remission rates with current medical treatments for inflammatory bowel disease.
Methods We searched MEDLINE (source PUBMED, 1966 to January, 2011).
Results Induction and maintenance of remission was observed in 20% (range, 9–29.5%) and 53% (range, 36.8–59.6%) of ulcerative colitis (UC) patients treated with oral 5-ASA derivatives. Induction of remission was noted in 52% (range, 48–58%) of Crohn's disease (CD) patients and 54% of UC patients treated with steroids in population-based cohorts. Maintenance of remission was reported in 71% (range, 56–95%) of CD patients on azathioprine over a 6-month to 2-year period and in 60% (range, 41.7–82.4%) in UC at 1 year or longer. Induction and maintenance of remission was noted in 39% (range, 19.3–66.7%) and 70% (range, 39–90%) of CD patients on methotrexate over a 40-week period. Induction of remission was reported in 32% (range, 25–48%), 26% (range, 18–36%) and 20% (range, 19–23%) of CD patients on infliximab, adalimumab or certolizumab pegol, respectively. The corresponding figures were 45% (range, 39–59%), 43% (range, 40–47%) and 47.9% at weeks 20–30 among initial responders. Induction of remission was observed in 33% (range, 27.5–38.8%) and 18.5% of UC patients on infliximab or adalimumab, respectively. Maintenance of remission was noted in 33% (range, 25.6–36.9%) of UC patients on infliximab at week 30. Approximately one-fifth of CD and UC patients treated with biologicals require intestinal resection after 2–5 years in referral-centre studies.
Conclusion In the era of biologics, the proportion of patients with inflammatory bowel disease not entering remission remains high.
Introduction
The management of failed medical treatment for inflammatory bowel diseases (IBD) remains a challenge. Failed medical treatment can be defined as primary nonresponse or loss of response (absence of remission) in primary responders to a given drug regimen. Drug intolerance leading to drug discontinuation should be also part of the definition of failure. The ultimate goal should be remission.
In clinical practice the first step is to rule out symptoms not related to disease activity and intestinal inflammation. Notably, exclusion of mechanical problems (stricture, fistula, short bowel), undiagnosed infection (from abscesses to enteric infections, Clostridium difficile, parasites or tuberculosis); the assessment of malnutrition should be part of the management of failed medical treatment. Loss of response should be confirmed by using serum (C-reactive protein) and faecal (calprotectin, lactoferrin) markers, as well as radiological (ultrasound, computed tomography, magnetic resonance imaging) and/or endoscopic evaluation. The therapeutic armentarium for IBD mainly comprises 5-aminosalicylates (5-ASA), steroids, ciclosporin, thiopurines, methotrexate, antitumour necrosis agents, (anti-TNF) agents and in the United States (US), natalizumab. In 2011, a step-up approach is recommended for most patients with IBD. In case of failure of medical treatments, surgery should be considered.
In this review we summarise available data remission for each drug class with a focus on results from randomised, controlled trials. We will then review the need for surgery in IBD in the era of biological agents.
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