David Rubin, MD, on Evolving Goals in the Management of Ulcerative Colitis

Dr Rubin discusses the evolution of treatment goals with ulcerative colitis, including discussing with patients quality of life issues, urgency, functionality, and the potential for remission.

David Rubin, MD, is the Joseph B Kirsner Professor In Medicine, chief of Gastroenterology, Hepatology and Nutrition, and director of the Digestive Diseases Center at the University of Chicago School of Medicine.

TRANSCRIPT:

Hi, I'm David Rubin from the University of Chicago, and I'm speaking to you from the Crohn's and Colitis Congress in Denver, Colorado 2023. And I wanted to share with you a bit of what I've presented at this meeting combined into one brief summary. I've had a couple presentations here about ulcerative colitis, and I thought it'd be helpful to share the evolving goals of managing ulcerative colitis, which have come up in these different presentations. We've made some progress in this specific space, and I think it's really important as people who take care of patients who live with ulcerative colitis, and of course the patients who are living with ulcerative colitis, that we get on the same page here. We want people who have these conditions, first of all, to know that they should be in remission. That may sound obvious to those of us who take care of these patients, but there are a lot of patients who have not achieved that goal yet—and a lot of people living with ulcerative colitis who don't realize that that's actually what we're trying to accomplish or that it's even possible. It is possible.

Remission is defined in a number of ways and that definition has evolved. It includes, of course, having reduced stool frequency back to a baseline of normal stools, the absence of rectal bleeding. But very importantly, it's also the recognition that urgency should be gone. When I was in training, we talked about asking patients about urgency, but it hasn't been until much more recently that we codified it in the ACG guidelines for ulcerative colitis. And then more recently even still, that there was the development of a numeric rating score for urgency. The bottom line here is that we should be asking patients whether they're experiencing urgency from their condition and recognize that even when they tell us their stool frequency and rectal bleeding is improved, and even when their endoscopy looks better, they may still be experiencing urgency.

So that's an important question to be asking. And if we don't ask about it, it may not even come up. Some of this urgency may be due to persistent inflammation. Some may be based on our hypothesis that the rectum doesn't stretch, or store, or squeeze, like it used to because of transmural inflammation or damage that has occurred. And some may be due to other factors that we need to understand, but it is definitely true that patients with persistent urgency have a reduced quality of life, and it absolutely impacts their ability to function.

The other part of understanding remission in ulcerative colitis is of course tying it to other objective measures of disease control. And that currently includes endoscopy and demonstrating of course, that the mucosal looks healed or nearly healed, and we accept biomarkers as a surrogate of that. The most direct one in ulcerative colitis is usually fecal calprotectin.

The pearl about fecal calprotectin is that you really do need to understand two things. Number one, benchmark it against the active disease so you know that you're looking at an improvement over time, to get it less than ideally 150 as a marker that you've gotten to where you need to be. And the second thing to keep in mind about fecal calprotectin is you can have a false positive in patients who have inflammatory polyps when the rest of their bowel is actually healed. So if the patient says they're feeling great, but their calpro remains very high, you should investigate with a scope and then figure out what's going on.

Now, the other evolving definition for remission in colitis is the recognition of some additional factors that we must be thinking about. One of them is the ability of the patient to have intimate relations and sexual activity—something else we don't ask about enough, and which we know people with colitis and Crohn's disease really experience. And the other one is the recognition about fatigue, which is relatively ubiquitous among our patients with IBD, and obviously could be multifactorial. But asking about it and knowing that it's part of what we want to treat and understand is critical to taking care of our patients.

So as you can see, we have started to broaden what we think about in terms of getting these diseases under control, and patients should expect not just remission, but functional remission, being able to do what they need to do in life, and more. And we should be working hard to make sure we get them there. And simultaneously, the research and clinical trials need to better understand how we can do that effectively.

My last comment is to please ask you to join the Crohn's and Colitis Foundation. We have seen an increase in our professional membership. The foundation in the United States is the only organization that serves both patients and all the healthcare professionals, and we really want you to be part of that and to support that organization so they continue to do the work that they are doing.