Lower Risk for Relapse in Patients With Clinical and Endoscopic Remission of Ulcerative Colitis

A team of investigators conducted a systematic review to estimate the risk of relapse in patients with ulcerative colitis in remission.

Patients achieving clinical and endoscopic remission of ulcerative colitis (UC) symptoms were found to have a lower risk for clinical relapse compared with patients with only clinical remission, according to findings from a systematic review and random effects meta-analysis published in Gastroenterology.

Publication databases were searched and cohort studies (N=17) of adults with UC (N=2608) investigating clinical remission with ≥1-year follow-up were included. The studies compared the risk of clinical relapse in patients who achieved endoscopic remission (Mayo endoscopy subscore [MES] of 0) vs those with mildly active disease (MES 1), as well as vs patients achieving histologic remission vs persistent histologic activity.

Among all studies, patients achieving endoscopic remission (MES 0) were found to have a 52% lower risk for clinical relapse compared with those with mild endoscopic activity (MES 1), with a reported risk ratio (RR) of 0.48 (95% CI, 0.37-0.62). Substantial heterogeneity was observed between these studies (I2, 62%).

Among the 8 studies of patients with MES of 1, median 12-month clinical relapse was 28.7%; using this rate the investigators estimated an annual risk for remission among patients with MES 1 as 13.7% (95% CI, 10.6%-17.9%).

In a subanalysis of 10 studies, patients with MES of 0 were found to have a 63% lower risk of clinical relapse compared with patients with persistent histologic activity (RR 0.37; 95% CI, 0.24-0.56).  For these patients, the investigators estimated an annual risk for clinical relapse of 5.0% (95% CI, 3.3-7.7).

Between 45% and 55% of the studies were considered at high risk for bias due to outcome  measurement, confounding due to failure to adjust for key factors, and unadjusted statistical analysis and reporting.

The risk for clinical relapse varied based on follow-up time and bias risk. When comparing the risk for MES 0 vs MES 1, studies with a median follow-up >12 months reported a lower risk (RR, 0.39) than studies with a median follow-up time of 12 months (RR, 0.60; P =.097). Similarly, studies at higher risk for bias in outcome measurement reported a lower risk for relapse (RR, 0.31) compared with studies with lower bias (RR, 0.62; P <.01).

Limitations of the study include variability in the definition of histologic remission, outcome measurements, validation of disease activity, and varying cut-off levels that contributed to substantial heterogeneity in some estimates.

The conclusion drawn from these data was that patients with UC in endoscopic and histologic remission were found to have lower rates of clinical relapse when compared with patients achieving clinical remission alone.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

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Yoon H, Jangi S, Dulai PS, et al. Incremental benefit of achieving endoscopic and histologic remission in patients with ulcerative colitis: a systematic review and meta-analysis [published online June 22, 2020]. Gastroenterology. doi:10.1053/j.gastro.2020.06.043