What to check for in patients with ulcerative colitis (UC)?

From the Guidelines

When evaluating patients with ulcerative colitis, clinicians should prioritize a biomarker- and symptom-based monitoring strategy, using fecal calprotectin, fecal lactoferrin, and CRP to inform disease management and avoid routine endoscopic assessment, as recommended by the most recent guidelines 1. This approach is supported by the latest evidence, which suggests that noninvasive biomarkers can effectively inform disease monitoring and management in patients with ulcerative colitis 1.

Key Components of Evaluation

• Symptom review: bloody diarrhea, abdominal pain, urgency, tenesmus
• Physical examination: abdominal tenderness
• Laboratory tests: complete blood count, inflammatory markers (CRP, ESR, fecal calprotectin), and liver function tests
• Endoscopic evaluation with colonoscopy: essential for diagnosis and monitoring, but may not be necessary for routine assessment in patients with normal biomarkers and symptoms in remission 1
• Stool studies: to rule out infectious causes
• Nutritional status: weight changes, albumin levels, and vitamin/mineral deficiencies (particularly iron, B12, folate, and vitamin D)
• Medication adherence and side effects: monitoring for steroids, immunomodulators, and biologics
• Extraintestinal manifestations: joints, skin, eyes, and liver
• Screening for complications: colorectal cancer (surveillance colonoscopy every 1-3 years after 8 years of disease)
• Psychological well-being: assessment for anxiety and depression

Biomarker-Based Monitoring Strategy

The use of a biomarker-based monitoring strategy has been suggested as a reasonable approach for patients with ulcerative colitis in symptomatic remission, with the goal of avoiding routine endoscopic assessment 1.

• Fecal calprotectin <150 mg/g, normal fecal lactoferrin, and/or normal CRP: suggests inactive inflammation and may avoid routine endoscopic assessment
• Elevated biomarkers: may warrant endoscopic assessment to inform treatment decisions However, it is essential to note that the performance of biomarkers may be modest for detecting endoscopic remission and histologic remission, which are associated with more favorable long-term outcomes 1.

Implementation Considerations

In patients with ulcerative colitis in symptomatic remission but elevated biomarkers, repeat measurement of biomarkers (in 3–6 months) may be a reasonable alternative to endoscopic assessment, but endoscopic evaluation may be warranted if biomarkers remain elevated 1. Overall, a comprehensive evaluation of patients with ulcerative colitis is crucial to assess disease activity, monitor treatment response, and screen for complications, with the goal of improving morbidity, mortality, and quality of life.

From the FDA Drug Label

The improvement with infliximab was consistent across all Mayo subscores through Week 54 (Study UC I shown in Table 6; Study UC II through Week 30 was similar) Table 6 Proportion of patients in Study UC I with Mayo subscores indicating inactive or mild disease through Week 54 Clinical response at Week 8 was defined as a decrease from baseline in the Mayo score by ≥ 30% and ≥ 3 points, including a decrease in the rectal bleeding subscore by ≥ 1 points or achievement of a rectal bleeding subscore of 0 or 1. Clinical remission at Week 8 was measured by the Mayo score, defined as a Mayo score of ≤ 2 points with no individual subscore >1 Remission was defined as an Ulcerative Colitis Disease Activity Index (UC-DAI) of ≤ 1, with scores of zero for rectal bleeding and for stool frequency, and a sigmoidoscopy score reduction of 1 point or more from baseline.

Key factors to check for in patients with ulcerative colitis:

• Mayo score: decrease from baseline by ≥30% and ≥3 points
• Rectal bleeding subscore: decrease by ≥1 points or achievement of a rectal bleeding subscore of 0 or 1
• Stool frequency: score of zero
• Sigmoidoscopy score: reduction of 1 point or more from baseline
• Ulcerative Colitis Disease Activity Index (UC-DAI): ≤ 1, with scores of zero for rectal bleeding and for stool frequency
• Clinical remission: Mayo score of ≤ 2 points with no individual subscore >1 2 3

From the Research

Diagnosis and Monitoring of Ulcerative Colitis

To check for ulcerative colitis in patients, the following should be considered:

• Clinical presentation, including symptoms such as bloody diarrhea, rectal urgency, tenesmus, and abdominal pain 4
• Endoscopic findings, including ileocolonoscopy with biopsy to confirm the diagnosis and assess the extent and severity of inflammation 4, 5
• Histopathology to assess disease severity and identify intraepithelial neoplasia (dysplasia) or cancer 4
• Laboratory tests, including inflammatory markers such as high sensitivity C-reactive protein (hs-CRP) and C-reactive protein to albumin ratio (CAR) 6
• Imaging studies, such as abdominal computed tomographic (CT) scanning, to evaluate the extent of disease and detect complications 4

Disease Severity and Extent

The extent and severity of ulcerative colitis can be assessed using various indices and scoring systems, including:

• The Mayo scoring system to assess disease severity and monitor patients during therapy 4, 5
• The Mayo endoscopic score (MES) to evaluate endoscopic disease activity 6
• Disease extent, including proctitis, proctosigmoiditis, left-sided colitis, and pan-colitis 5

Monitoring and Surveillance

Ongoing monitoring of ulcerative colitis is crucial and may include:

• Repeated clinical assessments over time 7
• Measuring noninvasive markers of inflammation, such as hs-CRP and CAR 6
• Endoscopic and histologic reevaluation to assess disease activity and detect dysplasia or colorectal neoplasia 7
• Dysplasia surveillance, taking into account patient-specific risk factors 7