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Clinical implications of mucosal healing for the management of IBD

Abstract

Mucosal healing (MH) has emerged as an important treatment goal for patients with IBD. Historically, the therapeutic goals of induction and maintenance of clinical remission seemed insufficient to change the natural history of IBD. Evidence has now accumulated to show that MH can alter the course of IBD, as it is associated with sustained clinical remission, and reduced rates of hospitalization and surgical resection. In patients with ulcerative colitis, MH may represent the ultimate therapeutic goal because inflammation is limited to the mucosa. In patients with Crohn's disease, which is a transmural disease, MH could be considered as a minimum therapeutic goal. This Review focuses on the definition of MH and discusses the ability of each available IBD medication to induce and maintain MH. The importance of achieving MH is also discussed and literature that demonstrates improvement of disease course with MH is reviewed. Finally, we discuss how best to integrate the treatment end point of MH into clinical practice for the management of patients with IBD.

Key Points

  • The ideal definition of mucosal healing (MH) could be complete endoscopic healing of all inflammatory and ulcerative lesions of the gut mucosa in Crohn's disease (CD) and ulcerative colitis (UC)

  • In CD, an endoscopic response to treatment can be defined as a significant change of endoscopic disease activity score, such as the CDEIS or the SES-CD

  • In UC, MH can be achieved with corticosteroids, 5-aminosalicylates, immunosuppressive drugs and biological agents, and can be maintained with 5-aminosalicylates, immunosuppressive drugs and biological agents

  • In CD, MH can be achieved with corticosteroids, enteral nutrition (in pediatric patients), immunosuppressive drugs and biological agents, and can be maintained with immunosuppressive drugs and biological agents

  • MH is a more objective end point than clinical remission for evaluating inflammatory disease activity and should be used in both therapeutic trials and clinical practice for the management of IBD

  • MH can alter the natural history of IBD by reducing hospitalization rate and the lifetime risk for surgery

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Figure 1: The Mayo endoscopic subscore for the assessment of disease activity in patients with ulcerative colitis including endoscopic images of ulcerative colitis that are representative of the scale of disease.
Figure 2: Kaplan–Meier curves from a Norwegian population-based study showing influence of MH on outcomes in patients with IBD.

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Acknowledgements

Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Correspondence to Jean-Frédéric Colombel.

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G. Pineton de Chambrun declares no competing interests. L. Peyrin-Biroulet is a Consultant for Abbott and UCB, receives research support from UCB and is on the Speaker's bureau for Centocor. J.F. Colombel is a Consultant and is on the Speaker's bureau for Abbott, Centocor JCB, Schering Plough and UCB. M. Lémann is on the Speaker's bureau for Abbott, Astra, Ferring, Schering Plough, Shire, PDL and UCB. He has received study grants or educational grants from Abbott, Astra, BMS, Ferring, Sanofi-Aventis, Schering Plough, Shire, Novartis, PDL, Novartis and UCB. He is a Consultant for Abbott, Centocor, Elan, Ferring, Millenium, Schering Plough, Shire, Novartis, Pfizer, PDL and UCB.

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Pineton de Chambrun, G., Peyrin-Biroulet, L., Lémann, M. et al. Clinical implications of mucosal healing for the management of IBD. Nat Rev Gastroenterol Hepatol 7, 15–29 (2010). https://doi.org/10.1038/nrgastro.2009.203

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