Updated AGA guidelines urge use of biomarkers for the management of UC
Click Here to Manage Email Alerts
New AGA clinical practice guidelines highlight the role of noninvasive biomarkers, including fecal calprotectin, fecal lactoferrin and C-reactive protein, for the management of patients with ulcerative colitis.
“Despite the fact that early proactive assessment of bowel inflammation is associated with superior long-term outcomes, there is significant variability in utilization,” Siddharth Singh, MD, assistant professor of medicine at the University of California, San Diego, and colleagues wrote in Gastroenterology. “Moreover, in routine clinical practice, repeated endoscopic assessment is invasive, expensive and may be impractical.”
They continued, “There is an important need for understanding how noninvasive biomarkers may serve as accurate and reliable surrogates for endoscopic assessment of inflammation and whether they can be more readily implemented in a UC care pathway.”
Using the Grading of Recommendations Assessment, Development and Evaluation framework, Singh and colleagues prioritized clinical questions, identified patient-centered outcomes and analyzed clinical performance of serum CRP, fecal calprotectin and fecal lactoferrin as disease activity biomarkers in patients with UC.
Highlights of the seven conditional recommendations include:
- Monitoring strategy should include biomarkers and symptoms, rather than symptoms alone, in patients with active UC, as well as those in symptomatic remission.
- Fecal calprotectin less than 150 µg/g, normal fecal lactoferrin or normal CRP can be used to rule out active inflammation in patients in symptomatic remission. Avoid additional routine endoscopic assessment of disease activity.
- For patients in symptomatic remission with elevated inflammation markers (fecal calprotectin > 150 µg/g, elevated fecal lactoferrin or elevated CRP), or moderate to severe symptoms and normal biomarkers, use endoscopic assessment to inform treatment decisions.
- For patients with mild symptoms and normal inflammation biomarkers, use endoscopic assessment to inform treatment decisions.
- Patients with moderate to severe symptoms suggestive of flare should be evaluated using fecal calprotectin greater than 150 µg/g, elevated fecal lactoferrin or elevated CRP to rule in active inflammation.
The AGA made no recommendation in favor of or against a biomarker-based monitoring strategy over endoscopy-based monitoring, as more information is needed. “The evidence panel identified numerous knowledge gaps in the literature where there were insufficient data to inform recommendations,” Singh and colleagues wrote.
Future research, they noted, should include analysis on the timing of measuring biomarkers, biomarker-based treat-to-target strategies, prognostic significance of biomarkers and biomarker performance in diverse populations.
Perspective
Back to Top
Miguel Regueiro, MD
The guideline on the role of biomarkers for the management of UC confirms the importance of these biomarkers, fecal calprotectin, CRP and fecal lactoferrin in the assessment of UC.
Historically, endoscopic evaluation — such as flexible sigmoidoscopy or colonoscopy — was the only diagnostic tool available for assessing active bowel inflammation in patients with UC. With the advent of biomarkers over the past several years, especially fecal calprotectin, there is a noninvasive method by which to assess inflammation.
The authors outline several scenarios in which biomarkers are useful in determining the presence of active inflammation in the colon, such as in patients with symptomatic remission as a way to monitor for colitis without relying on symptoms or requiring a colonoscopy for active colitis assessment. Importantly, a fecal calprotectin of less than 150 µg/g effectively “rules out” active inflammation, whereas a level of greater than 150 µg/g suggests active inflammation.
The guideline makes good sense and is consistent with my own practice. That is, I have been measuring fecal calprotectin and CRP one to two times per year in asymptomatic UC patients to assess for inflammation and, if less 150 µg/g, forego a routine annual colonoscopy, unless indicated for surveillance of dysplasia. Similarly, for patients with a change of symptoms, I often measure fecal calprotectin (and CRP) and, if greater than 150 µg/g, proceed with endoscopic assessment.
It should be noted that pairing the inflammatory markers with a recent endoscopic evaluation is important (eg, a patient with active UC on colonoscopy who also has a fecal calprotectin greater than 150 µg/g or a patient with UC in colonoscopic remission and fecal calprotectin less 150 µg/g). Thereby, the fecal calprotectin may be used as a surrogate biomarker for inflammation (in a patient who had been in remission) or improvement of inflammation (in a patient symptomatically responding to UC treatment) over time.
Collapse
Read more about
Click Here to Manage Email Alerts