Incremental Benefit of Achieving Endoscopic and Histologic Remission in Patients With Ulcerative Colitis: A Systematic Review and Meta-Analysis

Abstract

Background & Aims: Clinical remission, defined by a composite of patient reported outcomes and Mayo endoscopy subscore (MES) 0 or 1 is a recommended treatment target in patients with ulcerative colitis (UC). We estimated whether incorporating more rigorous remission definitions, of endoscopic remission (MES 0) and histologic remission, affects risk of relapse.Methods: Through a systematic review, we identified cohort studies in adults with UC in clinical remission that reported a minimum 12-month risk of clinical relapse, based on MES (0 vs 1) and/or histologic disease activity, in patients with endoscopic remission. Using random effects meta-analysis, we calculated relative and absolute risk of clinical relapse in patients with UC achieving different treatment targets.Results: In a meta-analysis of 17 studies that included 2608 patients with UC in clinical remission, compared to patients achieving MES 1, patients achieving MES 0 had a 52% lower risk of clinical relapse (relative risk, 0.48; 95% CI, 0.37-0.62). The median 12-month risk of clinical relapse in patients with MES 1 was 28.7%; the estimated annual risk of clinical relapse in patients with MES 0 was 13.7% (95% CI, 10.6-17.9). In a meta-analysis of 10 studies in patients in endoscopic remission (MES 0), patients who achieved histologic remission had a 63% lower risk of clinical relapse vs patients with persistent histologic activity (relative risk, 0.37; 95% CI, 0.24-0.56). Estimated annual risk of clinical relapse in who achieved achieving histologic remission was 5.0% (95% CI, 3.3-7.7). Conclusions:In a systematic review and meta-analysis of patients with UC in clinical remission, we observed that patients achieving more rigorous treatment endpoints (endoscopic and histologic remission) have a substantially lower risk of clinical relapse compared with patients achieving clinical remission.

Letter: the combination of histologic remission and Mayo endoscopic score 1 as a suitable therapeutic target in ulcerative colitis—authors' reply

“…Our findings do not conflict with Maeda et al, but support that achievement of histologic remission in MES = 1 endoscopic disease provides benefit over and above attaining MES = 1 disease alone. While our findings do suggest that histologic remission may not provide additional benefit in patients who have achieved MES = 0 endoscopic remission, our recent meta‐analysis and systematic review support that histologic remission probably also confers additional benefit over MES = 0 endoscopic remission alone 3 …”

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“…Histological deep healing is the highest goal of clinical treatment for IBD patients. A recent systematic review and meta-analysis revealed that patients who achieved endoscopic and histological remission have a significantly lower risk of clinical relapse than patients who achieved clinical remission (Yoon et al, 2020). The proinflammatory cytokines levels correlate with the severity of colitis.…”

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“…For ulcerative colitis, clinical remission determined by rectal bleeding and stool frequency scores along with endoscopic remission were deemed the primary targets, with histological remission an adjunctive goal. The importance of aiming for deeper remission has been reinforced by a greater focus on the accumulation of progressive damage in IBD, 2 as well as evidence showing that even minor endoscopic and histologic abnormalities are associated with poorer subsequent clinical outcomes 3 …”

“…The importance of aiming for deeper remission has been reinforced by a greater focus on the accumulation of progressive damage in IBD, 2 as well as evidence showing that even minor endoscopic and histologic abnormalities are associated with poorer subsequent clinical outcomes. 3 The STRIDE consensus did not recommend the use of fecal biomarkers such as calprotectin as targets in their own right. However, more recent data lends support to the use of non-invasive biomarkers to inform treatment decisions.…”