In ulcerative colitis (UC), histological remission may predict long-term outcomes, including corticosteroid use and hospitalization, better than endoscopy, according to a recent study published online May 18 in Gut.
The study is the first to systematically evaluate how well histologic remission predicts long-term outcomes in UC compared with endoscopy, note Robert Bryant, MD, and colleagues at the John Radcliffe Hospital in Oxford, United Kingdom.
"The findings are striking but intuitive, adding weight to calls to include histological remission into definitions of the depth of remission for UC," they write "In the current scramble for biomarkers that might predict the future pattern of disease, traditional measures such as histology merit re-appraisal."
Treatment goals for UC include endoscopic remission, but continuing histological inflammation may remain. Previous studies have linked continuing histologic inflammation with increased risk for relapse, hospitalization, colectomy, and colorectal cancer, the authors note.
Therefore, the researchers enrolled 91 outpatients with UC from the John Radcliffe Hospital from November 2007 to March 2008.
At baseline, the authors performed blinded endoscopic and histologic assessments of participants. They defined endoscopic remission as a Baron score of 1 or lower, and histological remission using Truelove and Richards' index. In July 2014, they reviewed patients' medical records for clinical outcomes.
With a median follow-up of 72 months, the researchers found moderate overall agreement between endoscopic and histological remission (43% [42/91]; κ = 0.56; 95% confidence interval [CI], 0.36 - 0.77). During the study, 63% (57/91) of patients required oral corticosteroids and 22% (20/91) were hospitalized with acute severe colitis. Despite achieving endoscopic remission, 24% of patients had continuing microscopic inflammation.
Histologic remission predicted decreased corticosteroid use and hospitalization (hazard ratio [HR], 0.42 [95% CI, 0.2 - 0.9; P = .02]; HR, 0.21 [95% CI, 0.1 - 0.7; P = .02], respectively). Endoscopic remission, however, did not (corticosteroid use: HR, 0.86 [95% CI, 0.5 - 1.7; P = .65]; hospitalization: HR, 0.83 [95% CI, 0.3 - 2.4; P = .74], respectively).
Among patients with complete remission (as defined by both endoscopic and histologic remission), 43% needed corticosteroids during follow-up. In contrast, 78% of those in endoscopic remission but with continuing histologic inflammation needed corticosteroids (P = .02).
Patients in complete remission also had lower rates of hospitalization compared with those in endoscopic remission alone (12% vs 36%, respectively; HR, 0.24; 95% CI, 0.1 - 0.9; P = .04).
The authors note that the small number of patients could have limited the study. In addition, there were no validated indices of severity for endoscopic evaluation that existed at the time of the study, so use of the unvalidated Baron score could have further limited the study. Furthermore, histopathology for UC remains nonstandardized, and the distinction between active and disease in remission is not validated.
"These data lend weight to the importance of developing standardised and validated scoring indices to measure histological remission," the authors conclude. "Our findings support the inclusion of histopathology in both [inflammatory bowel disease] clinical trials and practice, which will require a paradigm shift in thinking among clinicians, towards a treatment target of 'complete remission' in UC."
The authors have disclosed no relevant financial relationships.
Gut. Published online May 18, 2015. Abstract
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Cite this: Ulcerative Colitis: Histology Predicts Long-term Outcomes - Medscape - May 26, 2015.
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