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The 2022 Asia-Pacific Digestive Disease Week Conference and the 22nd National Gastroenterology Conference of the Chinese Medical Association were held
online on November 17~20, 2022.
.
- Professor Wu Kaichun -
- Vice President of Xijing Gastroenterology Hospital
- Changjiang Scholar Distinguished Professor, National Outstanding Youth
- Vice Chairman of the Chinese Society of Gastroenterology
- Vice President of the Digestive Branch of the Chinese Medical Doctor Association
- Executive Committee Member and Foundation President of the World Society of Gastroenterology
- Secretary General of the Asia-Pacific Society of Gastroenterology
- Chairman of the All-Army Gastroenterology Professional Committee
- Leader of IBD Group of Chinese Society of Gastroenterology
What is ulcerative colitis? Ulcerative colitis (UC) is a chronic persistent inflammatory disease, a type of inflammatory bowel disease (IBD), lesions are mainly limited to the large intestine, always continuously affecting the rectum and part or all of the colon, generally not affecting the small intestine and anus
.
UC is characterized by diffuse mucosal inflammation
.
The diagnosis of UC relies mainly on endoscopy and pathological examination
.
Colonoscopy is one of the most important means of
diagnosing and differentiating diseases.
Endoscopic findings of UC are closely related to disease severity, and understanding the severity of endoscopic lesions can help clinicians judge the patient's condition and formulate appropriate treatment plans
.
If possible, confocal endoscopy can be used to identify subtle lesions
.
Current Status of UC Diagnosis in China: Heavy Disease Burden According to the IBD Blue Book: Report on Doctors' and Patients' Cognition and Quality of Life of Inflammatory Bowel Disease in China (hereinafter referred to as the Blue Book) released in 2021, UC has a heavier
disease burden.
UC affected the most extensive colonic type, accounting for 42.
2%.
46.
6% of respondents are in the active period of UC, of which more than 80%
are moderate to severe.
6.
4% of respondents had extraintestinal manifestations, among which erythematous nodules and ankylosing spondylitis accounted for a relatively high
proportion.
For the diagnosis of UC disease, respondents generally experienced delays in diagnosis, more than half of the respondents experienced misdiagnosis during the diagnosis and treatment, and more than a quarter of the respondents experienced at least three diagnoses before confirming UC.
UC Treatment Goals: The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II), newly released by the International IBD Research Organization, divides treatment goals into short-, medium- and long-term goals
.
Short-term treatment goals: clinical response [defined as at least a 50% reduction in rectal bleeding and stool frequency according to STRIDE-II as Patient Reported Outcomes (PRO)].
It is mainly aimed at rapid improvement in clinical symptoms
.
Medium-term treatment goals: clinical response [defined as PRO2 (rectal bleeding, stool frequency = 0) according to STRIDE-II, partial Mayo score <3 with no score >1] + biomarker compliance [normal C-Reactive Protein (CRP) + decreased fecal calprotectin (FC) to acceptable range].
STRIDE-II recommends that FC be reduced to 100-250 ug/g
.
Long-term treatment goal: endoscopic healing
.
STRIDE-II's specific recommendations for endoscopic evaluation of UC are as follows:
Endoscopic healing is the preferred long-term goal
.
If this goal has not been met, a change in treatment
regimen should be considered.
(Recommended strength: 8.
7%Votes: 87%)Endoscopic healing
can be assessed by sigmoidoscopy or colonoscopy.
(Recommended strength: 8.
3%Votes: 86%)Endoscopic healing at UC is defined as Mayo endoscopic score = 0, or UC Endoscopic Index of Severity (UCEIS) ≤1
.
(Recommended strength: 8.
5%%Votes: 85%)Histological remission is not a formal goal
of treatment.
Nevertheless, in UC, it can serve as an auxiliary indicator of endoscopic remission, representing a deeper level
of healing.
(Recommended strength: 7.
7; % votes: 80%)
However, there is still a gap
between the ideal and practice of mucosal healing in the clinic.
The results of the Blue Book survey show that in terms of conceptual cognition, more than half of doctors agree that "complete mucosal healing" must be achieved, but only 24% of respondents can actually achieve the treatment goal
of mucosal healing.
According to the Blue Book report, respondents who did not achieve mucosal healing were more likely to have worsening symptoms, which affected their quality of life
.
Among those who did not achieve mucosal healing, 57% of respondents experienced worsening symptoms within 3 months of maintenance therapy, much higher than the proportion of those who achieved mucosal healing (15%), and 59% of respondents who did not achieve mucosal healing believed that their symptoms affected quality of life, much higher than the proportion of those who achieved mucosal healing (23%)
.
Respondents who did not achieve mucosal healing were also more likely to relapse
.
The overall recurrence rate of UC respondents in the past year was about 80%, of which 70% of respondents who achieved mucosal healing would relapse UC, and the vast majority relapsed once; Among respondents who did not achieve mucosal healing, more respondents (83%) relapsed, and most relapsed three or more
.
Application and optimization of biologics in UC
Biologics currently approved for IBD include infliximab, adalimumab, certolizumab, golimumab, vedelizumab, and ustekinumab
.
Among them, the biologics approved for UC indications in China include infliximab and vedelizumab
.
Note: IBD, inflammatory bowel disease; CD, Crohn's disease; UC, ulcerative colitis; FDA, U.
S.
Food and Drug Administration; TNF, tumor necrosis factor; IL, interleukin
Each of these biologics is an effective treatment validated in well-designed randomized controlled trials, with Tumor Necrosis Factor Inhibitors (TNFi) being on the market the longest and the highest
cumulative quality of evidence.
For patients with moderate to severe UC, guidelines recommend early treatment with biologics
.
The 2020 American Gastroenterological Association (AGA) clinical practice guidelines for moderate to severe UC recommend early treatment with biologics with or without immunosuppressants
compared with slow escalation therapy after 5-amino salicic acid (5-ASA) treatment failure in outpatients with moderate to severe UC 。 If the severity of the disease is not high, and the safety of 5-ASA is highly concerned and the efficacy of the drug is not so important, a slowly ascending regimen
may be considered.
(Conditionally recommended, very low-certainty evidence)
Patients with moderate to severe UC with the following high-risk factors may be treated with descending ladders as appropriate:
Age at diagnosis< 40 years
.
Age < diagnosis is a high risk factor
for poor prognosis in UC patients.Extensive colonic lesions
.
Patients with UC with extensive colonic disease are more likely to develop colorectal cancer and are at higher risk of colectomy
.Endoscopic mucosal lesions are severe
.
Patients with UC who achieve mucosal healing after 1 year of treatment have a lower
risk of colectomy than those who do not.Low serum albumin, high CRP levels
.
CRP ≥30 mg/L at diagnosis of UC is a predictor of colectomy
.Associated with extraintestinal manifestations
.
Treatment should be individualized according to the severity and activity of intestinal lesions and extraintestinal manifestations, and anti-TNF-a drugs are effective
in treating a variety of extraintestinal manifestations.
For the selection of moderate to severe UC biologics, the AGA official professional review recommends the following:
In patients with moderate to severe UC who have not previously used biologic agents, infliximab may be superior to adalimumab (moderate-certainty evidence) and may be superior to golimumab, verolizumab, tofacitinib, and ustekinumab
in induction of remission.
(low- to very low-certainty evidence).Tofacitinib and ustekinumab may be superior to adalimumab and vedolizumab
in inducing remission in patients with moderate to severe UC who have previously received anti-TNF therapy.
(low-certainty evidence).
Application of traditional medicine in UC
Traditional drugs mainly include 5-ASA, immunosuppressants and glucocorticoids, and the applications of these drugs in UC are as follows:
5-ASA: mainly used for the treatment of mild to moderate UC, research data in moderate to severe UC are lacking
.
Immunosuppressants: previous guidelines/consensus recommend immunosuppressants as a treatment option for (1) hormone-resistant/dependent moderate to severe UC; (2) the choice of maintenance therapy; (3) Choice
of combination (TNFi) therapy.
The 2020 AGA guideline lowers the status of immunosuppressants in induction therapy and is only recommended as an option
for maintenance therapy and combination therapy.Glucocorticoids: effective and commonly used to induce moderate to severe UC remission, long-term use side effects and abuse should be noted
.
Management of acute and severe UC
For the management of acute and severe UC, the BSG guideline recommends the process as follows
.
The key points recommended by the guidelines are as follows: (1) the recommended time for flexible sigmoidoscopy is clarified; (2) clearly indicate the types of drugs that should be avoided in patients with acute and severe UC; (3) The assessment time of intravenous hormonal response was clearly 3 days; (4) It is necessary to actively adjust the dose of infliximab and carry out intensive therapy
in the stage of need.
brief summary
In China, there is a significant delay
in the diagnosis of UC.
Treatment goals need to be set in stages, divided into short-, medium- and long-term goals
.
The application and optimization of biologics in UC need to be strengthened, and traditional drug treatment is still irreplaceable
.
The management of acute and severe UC needs to be more standardized
.
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