Treat to Target in Inflammatory Bowel Disease: An Updated Review of Literature

Abstract

Therapeutic management of patients with inflammatory bowel diseases (IBDs) has, for years, been tailored towards monitoring patient clinical presentation as a way to gauge therapeutic management. With the advent of newer biological agents, treatment and management have begun to focus on more objective rather than subjective parameters. These objective parameters include endoscopic targets and focus on the impact of mucosal healing, radiologic and histologic targets, patient reported outcomes, and use of non-invasive biomarkers. However, a recent consensus statement has identified clinical/patient-reported outcome (PRO) remission and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1) as the target for UC with histological remission being an adjunctive goal. For CD, clinical/PRO remission defined as resolution of abdominal pain and diarrhea/altered bowel habit and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, and resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy were the primary targets. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. This approach requires continuous monitoring and therapeutic adjustments with an aim to achieve the target. This article attempts to review the most updated literature regarding the treat to target approach and thus provides current recommendations and supported evidence.

Fecal calprotectin measurement is a marker of short-term clinical outcome and presence of mucosal healing in patients with inflammatory bowel disease

“…Such knowledge would, then, allow for modifications in the treatment strategy, in order to avoid recurrence of overt inflammation. This approach is in line with the recent reappraisal of therapeutic goals in IBD with the introduction of the “treat-to-target” principle[ 3 ]. According to the latter concept, clinical remission should be paired with biological and endoscopic evidence of mucosal inflammatory inactivity in IBD patients.…”

A Treat-to-Target Update in Ulcerative Colitis: A Systematic Review

“…In 10%–15% of patients, UC can ultimately lead to colectomy (7). Achieving mucosal healing via treatment lowers the risk of requiring colectomy (7–9), which is important, because colectomy provides symptomatic relief, but no cure, and is associated with complications in up to a third of patients (10). UC management focused on symptomatic control may leave less active or smoldering disease (i.e., mucosal healing unachieved) lingering, risking future relapse (11).…”

“…In 2015, the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) committee defined the treat-to-target (T2T) approach for inflammatory bowel disease (IBD), which shifted the goal of UC treatment to long-term prevention of disease complications (dysplasia/cancer, hospitalizations, colectomy) and proposed monitoring of objective disease activity measurements (e.g., endoscopic evidence of inflammation) (2,12,13). The T2T approach, adapted from the rheumatoid arthritis paradigm, aims to achieve disease remission by adjusting therapy according to the achievement (or not) of predefined treatment response targets (2,9,13). The STRIDE committee proposed a composite target of normalization of bowel habits and intestinal inflammation, but evidence was limited for the incorporation of histology and biomarker targets (13).…”

Faecal calprotectin is the biomarker that best distinguishes remission from different degrees of endoscopic activity in Crohn’s disease

“…Since effective control of the inflammatory process is reflected in the healing of the intestinal mucosa and the healed mucosa is directly related to a lower recurrence, lower complication rates and the need for surgical treatment; it is necessary, for effective clinical practice, to use methods that safely measure intestinal inflammation [5][6][7]. An efficient therapeutic approach should aim to control tissue inflammation for mucosal healing and improve patient prognosis [8][9][10][11][12]. Frequent, objective, and regular evaluations of the inflammatory process are necessary to guide therapy [4,13].…”