Korean J Gastroenterol.  2015 May;65(5):268-272. 10.4166/kjg.2015.65.5.268.

Changing Paradigm in the Management of Inflammatory Bowel Disease

Affiliations
  • 1Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea. jbi@med.yu.ac.kr

Abstract

Inflammatory bowel disease (IBD) is a chronic progressive idiopathic inflammatory disorder that involves the digestive tract from the mouth to the anus. Over the past decades, many therapeutic strategies have been developed to manage IBD, but therapeutic strategies based only on relief of clinical symptoms have not changed the natural history of this disease entity. This underlines the importance of understanding the natural history of IBD itself. When we look at the natural history of Crohn's disease (CD), it first begins with inflammation of the intestinal mucosa and this inflammatory reaction proceeds to stenosing or penetrating reaction if not adequately controlled. However, it takes a considerable amount of time before mucosal inflammation proceeds to stenosis of the intestinal lumen or penetration into the adjacent bowel. Therefore, it can be expected that if proper care is given during that period, progression of CD to such a complicated disease could be prevented. Even though the concept of mucosal healing was introduced in the early 1990s, no correlation could be observed between healing of mucosal lesions and relief of clinical symptoms. However, the introduction of biologic agents targeting tumor necrosis factor has changed the way to treat IBD that is refractory to standard medications and has allowed us to aim for a new therapeutic goal, 'deep remission'. Further advances in biologic agents have provided highly effective treatments for IBD, making deep remission a realistic goal. Whether IBD patients may benefit by experiencing a 'deep' remission beyond the control of clinical symptoms need to be evaluated in further investigation. Nevertheless, it can be anticipated that attaining deep remission might ultimately have an impact on important outcomes such as the need for surgery and the quality of life.

Keyword

Inflammatory bowel diseases; Crohn disease

MeSH Terms

Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
Antibodies, Monoclonal/therapeutic use
Colitis, Ulcerative/drug therapy/metabolism/pathology
Crohn Disease/drug therapy/metabolism/pathology
Humans
Inflammatory Bowel Diseases/drug therapy/metabolism/*pathology
Intestinal Mucosa/metabolism/pathology
Mesalamine/therapeutic use
Tumor Necrosis Factor-alpha/immunology/metabolism
Anti-Inflammatory Agents, Non-Steroidal
Antibodies, Monoclonal
Mesalamine
Tumor Necrosis Factor-alpha

Reference

References

1. Code CD. A case of regional ileitis (Crohn's disease) with discussion. J R Nav Med Serv. 1947; 33:111–115.
Article
2. Langholz E. Ulcerative colitis. An epidemiological study based on a regional inception cohort, with special reference to disease course and prognosis. Dan Med Bull. 1999; 46:400–415.
3. Bassi A, Dodd S, Williamson P, Bodger K. Cost of illness of inflammatory bowel disease in the UK: a single centre retrospective study. Gut. 2004; 53:1471–1478.
Article
4. Ha C, Kornbluth A. Mucosal healing in inflammatory bowel disease: where do we stand? Curr Gastroenterol Rep. 2010; 12:471–478.
Article
5. Thia KT, Sandborn WJ, Harmsen WS, Zinsmeister AR, Loftus EV Jr. Risk factors associated with progression to intestinal complications of Crohn's disease in a population-based cohort. Gastroenterology. 2010; 139:1147–1155.
Article
6. Bernklev T, Jahnsen J, Lygren I, Henriksen M, Vatn M, Moum B. Health-related quality of life in patients with inflammatory bowel disease measured with the short form-36: psychometric assessments and a comparison with general population norms. Inflamm Bowel Dis. 2005; 11:909–918.
Article
7. Iacucci M, Ghosh S. Looking beyond symptom relief: evolution of mucosal healing in inflammatory bowel disease. Therap Adv Gastroenterol. 2011; 4:129–143.
Article
8. Greenberg GR, Feagan BG, Martin F, et al. Oral budesonide for active Crohn's disease. Canadian Inflammatory Bowel Disease Study Group. N Engl J Med. 1994; 331:836–841.
9. van Dullemen HM, van Deventer SJ, Hommes DW, et al. Treatment of Crohn's disease with anti-tumor necrosis factor chimeric monoclonal antibody (cA2). Gastroenterology. 1995; 109:129–135.
Article
10. Travis SP, Schnell D, Krzeski P, et al. Developing an instrument to assess the endoscopic severity of ulcerative colitis: the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). Gut. 2012; 61:535–542.
Article
11. Osterman MT. Mucosal healing in inflammatory bowel disease. J Clin Gastroenterol. 2013; 47:212–221.
Article
12. Smedh K, Olaison G, Franzén L, Sjödahl R. The endoscopic picture reflects transmural inflammation better than endoscopic biopsy in Crohn's disease. Eur J Gastroenterol Hepatol. 1996; 8:1189–1193.
Article
13. Mary JY, Modigliani R. Development and validation of an endoscopic index of the severity for Crohn's disease: a prospective multicentre study. Groupe d'Etudes Thérapeutiques des Affections Inflammatoires du Tube Digestif (GETAID). Gut. 1989; 30:983–989.
14. Daperno M, D'Haens G, Van Assche G, et al. Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD. Gastrointest Endosc. 2004; 60:505–512.
Article
15. Orlando A, Guglielmi FW, Cottone M, Orlando E, Romano C, Sinagra E. Clinical implications of mucosal healing in the management of patients with inflammatory bowel disease. Dig Liver Dis. 2013; 45:986–991.
Article
16. Samuel S, Bruining DH, Loftus EV Jr, et al. Validation of the ulcerative colitis colonoscopic index of severity and its correlation with disease activity measures. Clin Gastroenterol Hepatol. 2013; 11:49–54.e1.
Article
17. Travis SP, Schnell D, Krzeski P, et al. Reliability and initial validation of the ulcerative colitis endoscopic index of severity. Gastroenterology. 2013; 145:987–995.
Article
18. Wright R, Truelove SR. Serial rectal biopsy in ulcerative colitis during the course of a controlled therapeutic trial of various diets. Am J Dig Dis. 1966; 11:847–857.
Article
19. Rutgeerts P, Van Assche G, Sandborn WJ, et al. Adalimumab induces and maintains mucosal healing in patients with Crohn's disease: data from the EXTEND trial. Gastroenterology. 2012; 142:1102–1111.e2.
Article
20. Mader R, Keystone E. Optimizing treatment with biologics. J Rheumatol Suppl. 2007; 80:16–24.
21. Colombel JF, Louis E, Peyrin-Biroulet L, Sandborn WJ, Panacci-one R. Deep remission: a new concept? Dig Dis. 2012; 30(Suppl 3):107–111.
Article
22. Hay JW, Hay AR. Inflammatory bowel disease: costs-of-illness. J Clin Gastroenterol. 1992; 14:309–317.
23. Pariente B, Cosnes J, Danese S, et al. Development of the Crohn's disease digestive damage score, the Lémann score. Inflamm Bowel Dis. 2011; 17:1415–1422.
24. Sandborn WJ, Rutgeerts P, Feagan BG, et al. Colectomy rate comparison after treatment of ulcerative colitis with placebo or infliximab. Gastroenterology. 2009; 137:1250–1260. quiz 1520.
Article
25. Fr⊘slie KF, Jahnsen J, Moum BA, Vatn MH. IBSEN Group. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology. 2007; 133:412–422.
Article
26. Colombel JF, Sandborn WJ, Reinisch W, et al. SONIC Study Group. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med. 2010; 362:1383–1395.
Article
27. Thakkar K, Lucia CJ, Ferry GD, et al. Repeat endoscopy affects patient management in pediatric inflammatory bowel disease. Am J Gastroenterol. 2009; 104:722–727.
Article
28. Van Assche G, Dignass A, Reinisch W, et al. European Crohn's and Colitis Organisation (ECCO). The second European evi-dence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. J Crohns Colitis. 2010; 4:63–101.
29. Hanauer SB, Feagan BG, Lichtenstein GR, et al. ACCENT I Study Group. Maintenance infliximab for Crohn's disease: the ACCENT I randomised trial. Lancet. 2002; 359:1541–1549.
Article
30. Allez M, Lémann M. Role of endoscopy in predicting the disease course in inflammatory bowel disease. World J Gastroenterol. 2010; 16:2626–2632.
Article
31. Rutter M, Saunders B, Wilkinson K, et al. Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis. Gastroenterology. 2004; 126:451–459.
Article
32. Rutter MD, Saunders BP, Wilkinson KH, et al. Cancer surveillance in longstanding ulcerative colitis: endoscopic appear-ances help predict cancer risk. Gut. 2004; 53:1813–1816.
Article
33. Burger D, Travis S. Conventional medical management of inflammatory bowel disease. Gastroenterology. 2011; 140:1827–1837.e2.
Article
34. Hanauer SB, Sandborn WJ, Dallaire C, et al. Delayed-release oral mesalamine 4.8 g/day (800 mg tablets) compared to 2.4 g/day (400 mg tablets) for the treatment of mildly to moderately active ulcerative colitis: The ASCEND I trial. Can J Gastroenterol. 2007; 21:827–834.
35. Kamm MA, Sandborn WJ, Gassull M, et al. Once-daily, high-con-centration MMX mesalamine in active ulcerative colitis. Gastroenterology. 2007; 132:66–75. quiz 432–433.
Article
36. Mantzaris GJ, Christidou A, Sfakianakis M, et al. Azathioprine is superior to budesonide in achieving and maintaining mucosal healing and histologic remission in steroid-dependent Crohn's disease. Inflamm Bowel Dis. 2009; 15:375–382.
Article
37. Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005; 353:2462–2476.
Article
38. Rutgeerts P, Feagan BG, Lichtenstein GR, et al. Comparison of scheduled and episodic treatment strategies of infliximab in Crohn's disease. Gastroenterology. 2004; 126:402–413.
Article
39. Kavanaugh A, van der Heijde D, McInnes IB, et al. Golimumab in psoriatic arthritis: one-year clinical efficacy, radiographic, and safety results from a phase III, randomized, placebo-controlled trial. Arthritis Rheum. 2012; 64:2504–2517.
Article
40. Amiot A, Peyrin-Biroulet L. Current, new and future biological agents on the horizon for the treatment of inflammatory bowel diseases. Therap Adv Gastroenterol. 2015; 8:66–82.
Article
41. Sandborn WJ, Feagan BG, Marano C, et al. PURSUIT-Mainten-ance Study Group. Subcutaneous golimumab maintains clinical response in patients with moderate-to-severe ulcerative colitis. Gastroenterology. 2014; 146:96–109.e1.
Article
42. Feagan BG, Rutgeerts P, Sands BE, et al. GEMINI 1 Study Group. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2013; 369:699–710.
Article
Full Text Links
  • KJG
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr