For the first time in 10 years The American College of Gastroenterology has issued updated clinical guidelines on the management of ulcerative colitis (UC). Its approach has changed from addressing the treatment of Inflammatory Bowel Disease (IBD) symptoms, to add mucosal healing (MH). This means for the first time, doctors are being counseled to arrest disease progression, not to simply treat UC symptoms. The new guidelines were recently published in the American Journal of Gastroenterology.
According to one of the contributors to the guideline update, the changes look at UC from initial diagnosis and clinical management of the condition to the impact treatment has on quality of life. Detailed and categorized recommendations offer physicians a single source for updated clinical information.1
UC: what is it?
Ulcerative colitis (UC) is an immune-mediated inflammatory disorder with no known cause (idiopathic).2 Around 1 million people in the US have this chronic condition that affects the large intestine, and is often associated with inflammation of the rectum and additional areas of the colon.2 The disease is characterized by periods of flare-ups and remission of symptoms. It causes functional and structural damage to the mucosal (innermost) layer of the digestive tract resulting in rectal bleeding, diarrhea, pressure and pain.1,3
Mucosal healing: the definition
Mucosal healing is the repair of the inner tissue lining of the bowel, the absence of ulcers, and inflammation, which otherwise cause an active disease state.
Utilizing effective diagnostic, treatment, and preventive strategies, the goal is to treat the whole disease, including the healing of the inner layers of the bowel and intestine. Gastroenterologists and pathologists are looking for the absence of mucosal ulceration as a therapeutic target; seeing no disease activity during endoscopy or through biopsy analysis. This means via self-report, endoscopy and a histological evaluation.3 These can lead to a longer, healthier life with less likelihood of flare-ups and need for other invasive treatments that can include surgery.
The maintenance of a steroid-free remission is a significant treatment goal. It can lead to reductions of other clinical, medical, and psychological risk factors including the risk for developing colon cancer.2
People with UC can feel good and think they are in remission, but they may still experience internal inflammation and be subject to increased disease burden and incomplete mucosal healing.1 Response to treatment is based on individual risk factors. To achieve mucosal healing, resolving the inflammation, medical intervention can be reduced resulting in sustained steroid-free remission and the prevention of hospitalizations and surgery. Doctors can adjust doses and combine therapies to achieve desired results.4 Diagnostic evaluations should continue over time to evaluate the presence of any inflammation or other disease markers.
Mucosal healing: the benefits
People who have active disease are more likely to experience anxiety and depression as well as to find disruption in their social and professional lives. The new guidelines, which target treatment to healing, are likely to yield a prolonged state of bowel health resulting in improved quality of life.
Advances in diagnostic and clinical medicine can redirect treatment from the goal of symptomatic remission to disease-modification that improves patients’ long-term health.3 The availability of new therapeutic classes of medications, and development of sophisticated tools for selecting, optimizing, and evaluating the effectiveness of medications, has been demonstrated in clinical studies to improve care for people with UC.2
Long term effects
Mucosal healing leads to a better quality of life for people with UC.1 The updated care approach for ulcerative colitis is headed in a direction similar to management of diabetic conditions.1 In the past clinicians took a reactive approach, simply treating symptoms as they developed. The new approach focuses on being proactive, monitoring disease before people get sick to sustain remission.
The newly reported guidelines were developed using expert consensus. They view mucosal healing as the most significant factor in achieving favorable long-term outcomes.4 This is considered a preferred approach, but not the only way to guide treatment.2 As with all medical care, treatment modalities and rate of healing are individual.
Swift, D. Updated UC Guideline Adds Mucosal Healing to Treatment Goal. Available at: https://www.medscape.com/viewarticle/909801?src=wnl_edit_tpal&uac=14002MN&impID=1899444&faf=1. Accessed 3.7.19.
Rubin, D., Ananthakrishnan, et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Available at: Am J Gastroenterol. 2019. Accessed 3.7.19.
Mucosal healing in inflammatory bowel disease. Available at: https://www.mayoclinic.org/medical-professionals/digestive-diseases/news/mucosal-healing-in-inflammatory-bowel-disease/MAC-20430502. Accessed 3.7.19.
Tresca, A. What Is Mucosal Healing in IBD? Available at: https://www.verywellhealth.com/mucosal-healing-in-ibd-4427792. Accessed 3.7.19.