- Endoscopic remission/improvement is now considered an important therapeutic target for patients with ulcerative colitis (UC) but repeated endoscopic assessment is impractical in routine practice
- A panel of the American Gastroenterological Association has published recommendations about situations in which serum C-reactive protein, fecal calprotectin, and fecal lactoferrin can substitute for endoscopic assessment of UC
- For each recommendation, the guidance document discusses the rationale, key considerations for implementation, a summary of the evidence, the certainty of the evidence (moderate, low, or very low), and potential benefits versus harms
Over the past two decades, the therapeutic target in ulcerative colitis (UC) has shifted from symptom resolution alone to combining symptomatic and endoscopic remission/improvement. However, repeated endoscopic assessment is invasive and expensive, so it can be impractical in routine practice.
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The American Gastroenterological Association (AGA) has made official recommendations about using three biomarkers instead of endoscopic assessment of UC: serum C-reactive protein (CRP), fecal calprotectin, and fecal lactoferrin. These well-established, commonly available biomarkers can also be used for the longitudinal monitoring of patients with UC.
Ashwin N. Ananthakrishnan, MBBS, MPH, director of the Crohn's and Colitis Center at Massachusetts General Hospital and associate professor of Medicine at Harvard Medical School, and Siddharth Singh, MD, a gastroenterologist at the University of California at San Diego, are co–first authors of the guidelines, which appear in Gastroenterology.
Summary of Recommendations
As part of choosing its recommendations, the AGA panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to rate each one as "strong" or "conditional" (for the latter, specific tradeoffs and patient values are important to consider). It settled on seven conditional recommendations:
- Evaluation and monitoring should take into account both biomarkers and symptoms, not symptoms alone
Patients in symptomatic remission
- Use fecal calprotectin <150 mcg/g, normal fecal lactoferrin, or normal CRP to rule out active inflammation and avoid routine endoscopic assessment of disease activity
- In patients who have elevated stool or serum markers of inflammation (fecal calprotectin >150 mcg/g, elevated fecal lactoferrin, or elevated CRP), endoscopic assessment of disease activity is preferable to empiric treatment adjustment
Patients with symptomatically active UC
- Use fecal calprotectin >150 mcg/g, elevated fecal lactoferrin, or elevated CRP to rule in active inflammation and inform treatment adjustment; avoid routine endoscopic assessment solely for establishing the presence of active disease
- In patients who have mild symptoms, endoscopic assessment of disease activity is preferable to empiric treatment adjustment regardless of whether stool and serum markers of inflammation are normal or elevated
For each recommendation, the guidance document discusses the rationale, key considerations for implementation, a summary of the evidence, the certainty of the evidence (moderate, low, or very low), and potential benefits versus harms.
Other Information About Using Biomarkers
The AGA discusses laboratory evaluation of diarrhea in patients with suspected UC in earlier clinical practice guidelines and a technical review. The role of biomarkers in caring for patients with Crohn's disease will be discussed in a subsequent guideline.
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