Complete endoscopic healing linked with better Crohn’s outcomes
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Patients with Crohn’s disease who achieved complete mucosal healing experienced better outcomes than those who just had partial healing, according to study results.
Mathurin Fumery, MD, PhD, of Amiens University Hospital in France, and colleagues wrote that mucosal healing is considered a crucial therapeutic target in CD and has been explored in numerous studies.
“However, the optimal cutoff to change the course of CD is yet to be determined,” they wrote. “We therefore conducted a large retrospective multicenter study to investigate the long-term impact of complete endoscopic healing vs. partial endoscopic healing on the outcome of CD patients treated with biologics.”
Researchers performed a retrospective study comprising 84 patients with CD and mucosal healing who received a biologic therapy from 2008 to 2015. They compared outcomes of patients with CD endoscopic index scores (CDEIS) of 0 (complete healing) with CDEIS scores greater than 0 but less than 4 (partial healing). They defined the primary outcome of treatment failure as the need for biologic optimization, initiation of corticosteroids or a Harvey-Bradshaw score above 4 associated with change in treatment, disease-related hospitalizations or intestinal resection.
Over a median follow-up of 4.8 years, 27 patients experienced treatment failure (32%) and 3 underwent intestinal resection (3.6%). Treatment failure among patients with complete mucosal healing was 25%, while among patients with partial healing it was 48% (P = .045).
Compared with complete healing, patients with partial healing had shorter median time to treatment failure (21 months vs. 13 months) and higher rates of CD-related hospitalization (3.5% vs. 18%). Additionally, no patients with complete healing underwent resection.
Fumery and colleagues determined that having a CDEIS score greater than 0 but less than 4 was the only factor associated with treatment failure (HR = 2.6; 95% CI, 1.2–5.8).
“Similar to ulcerative colitis, a deeper endoscopic healing may be required to change disease course in CD,” they wrote. “Before systematically implementing these new findings in our clinical practice, this needs to be investigated in prospective ‘treat-to-target’ intervention trials comparing different targets for mucosal healing in CD.” – by Alex Young
Disclosures: Fumery reports receiving lecture and consultant fees from AbbVie, Boehringer, Ferring, Janssen, MSD, Pfizer and Takeda. Please see the full study for all other authors’ relevant financial disclosures.
Perspective
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Taha Qazi, MD
This is a good retrospective cohort study. The researchers were looking at a cohort of patients who have Crohn’s disease; one part of the cohort had been basically limited to no mucosal occurrence of disease while the other group had.
Participants were followed prospectively to see if they had developed any complications related to the disease whether it be hospitalizations, disease recurrence, or burdened biologic use.
The researchers saw better outcomes among patients who had mucosal healing.
The big limitations in this paper, and the researchers mentioned this, is that perfect can often be the enemy of good enough. When we have a disease where we’re looking at medications that we have four or five of and, in many ways with the treatment studies we’re looking at, the rates of mucosal healing are very low in general. For example, in the most recent VARSITY study, mucosal healing was around 20% to 30%.
For several reasons, it is hard for us to justify moving from one therapy to another therapy to another therapy when we have limited aspects in our own armamentarium.
Once again, this is going to change and as more drugs evolve, we are likely going to see both a movement of the flag posts and also a movement of our goals. Personally, from a clinical standpoint, I think this adds a lot of information regarding how mucosal healing is being interpreted, but in terms of would I change somebody to therapy from this disease to another disease? I do not know if that is something that I take away from this paper.
Only 20% of patients received drug healing or mucosal healing. There are very few drugs that I can say are approaching mucosal healing targets. So, if we do not necessarily have the tools to reach the endpoint can we really use that endpoint as our goal?
Ideally, the goal is mucosal healing to some degree, but “perfect” can be the enemy of “good enough” in our patients.
Until we find the drugs that can have significant, sufficient mucosal healing, all this research should be interpreted in the context of the drugs available.
From a clinical relevance standpoint, I worry that people who rely on mucosal healing as their target are going to cycle through our drugs quickly and that can be problematic considering the number of drugs currently available.
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