Predictors and Outcomes of Histological Remission in Ulcerative Colitis Treated to Endoscopic Healing

Sushrut Jangi; Hyuk Yoon; Parambir S. Dulai; Mark Valasek; Brigid S. Boland; Vipul Jairath; Brian G. Feagan; William J. Sandborn; Siddharth Singh

Disclosures

Aliment Pharmacol Ther. 2020;52(6):1008-1016. 

In This Article

Abstract and Introduction

Abstract

Background: Clinical remission is the recommended treatment target in ulcerative colitis. The predictors and outcomes of achieving histologic remission within a treat-to-target paradigm are not well established.

Aim: To evaluate the predictors and outcomes of achieving histologic remission in patients with ulcerative colitis treated-to-target of endoscopic healing (modified Mayo endoscopy score 0 or 1).

Methods: We conducted a retrospective cohort study in adults with active ulcerative colitis (modified Mayo endoscopy score 2 or 3), whose treatment was iteratively optimised to achieve endoscopic healing. We identified predictors of achieving histologic remission, and outcomes (risk of symptomatic relapse, and ulcerative colitis-related hospitalisation and/or surgery) of achieving histologic remission vs persistent histologic activity, using Cox proportional hazard analysis.

Results: Of the 411 patients with clinically active ulcerative colitis, 270 achieved endoscopic healing. Of the 270 patients, 55% simultaneously achieved histologic remission. Depth of endoscopic healing at final endoscopic assessment was the only independent determinant of histologic remission (modified Mayo endoscopy score 0 vs 1: odds ratio, 0.31 [95% confidence intervals, 0.18–0.52]). Over 28 months, achieving histologic remission was associated with a lower risk of clinical relapse (1-year cumulative risk: 18.7% vs 29.5%; adjusted hazard ratio, 0.56 [0.37–0.85]), and lower risk of hospitalisation (hazard ratio, 0.44 [0.20–0.94]). The incremental benefit of achieving histologic remission was observed only in patients achieving Mayo endoscopy score 1, but not Mayo endoscopy score 0.

Conclusions: In patients with active ulcerative colitis treated-to-target of endoscopic healing, 55% simultaneously achieved histologic remission. Histologic remission, particularly in patients achieving modified Mayo endoscopy score 1, was associated with favourable outcomes. Treating to a target of histologic remission over endoscopic healing requires prospective evaluation.

Introduction

Clinical remission, a composite outcome defined by a (PRO, patient reported outcome) of resolution of rectal bleeding and near normalisation of stool frequency and endoscopic healing based on MES 0 or 1, is the recommended treatment target in patients with UC, based on recent guidelines.[1] Approximately 50%-60% patients with EH achieve histologic remission, whereas others have persistent histological activity.[2] Histologic remission, regardless of clinical and endoscopic activity, may have superior long-term outcomes,[3–5] warranting its examination as a treatment target in patients with UC.[6] However, there are few studies specifically evaluating whether achievement of histologic remission among patients with active UC treated to a target of clinical remission has incremental benefit in clinical outcomes, especially in patients who have achieved MES 0. Furthermore, the feasibility and predictors of achieving histologic remission in the current treat-to-target paradigm remain uncharacterized.

Hence, we conducted a retrospective cohort study in patients with active UC who were treated-to-target of clinical remission comprised of both PRO remission and EH to (a) identify the feasibility and predictors of histologic remission during routine care, and to (b) analyse whether histologic remission provides incremental benefit in the likelihood of achieving relevant outcomes, including symptomatic relapse, hospitalization, and surgery.

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