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J Tradit Chin Med 2013 August 15; 33(4): 549-552
ISSN 0255-2922
© 2013 JTCM. All rights reserved.
REVIEW
TOPIC
How to achieve deep remission in treatment of inflammatory bowel
disease
Jie Han, Jian Wang, Jiaoying H. Wang
aa
Jie Han, the First Department of Digestology, the First Affiliated Hospital of Henan College of Traditional Chinese Medicine, Zhengzhou 450000, China
Jian Wang, Queensland Herbarium, Department of Environment and Resource Management, Brisbane Botanic Gardens, Brisbane 4066, Australia
Jiaoying H. Wang, School of Pharmacy, University of
Queensland, St. Lucia 4072, Australia
Correspondence to: Prof. Jie Han, the First Department of
Digestology, the First Affiliated Hospital of Henan College of
Traditional Chinese Medicine, Zhengzhou 450000, China.
han_ jie1974@163.com
Telephone: +86-13653868892
Accepted: January 23, 2013
possible to improve the prognoses of patients with
IBD by minimizing complications and bowel damage and thereby changing the course of the disease.
© 2013 JTCM. All rights reserved.
Key words: Inflammatory bowel diseases; Endoscopy, gastrointestinal; Medicine, Chinese traditional;
Lemann score; Deep remission
INTRODUCTION
Inflammatory bowel disease (IBD), including Crohn's
disease and ulcerative colitis, is a chronic, progressive,
and destructive disease that is able to induce disability
and severely influence affected patients' quality of life.1
Although IBD is characterized by the alternate occurrence of remission and relapse, it may produce persistent inflammation, leading to progressive bowel damage and complications such as stricture, fistulae, and
abscesses. These complications frequently require surgery, which may lead to further disability and higher
mortality.2 Disability among patients with IBD is commonly underestimated, but decreased quality of life is
well recognized among affected patients.
The goals of IBD management were formerly focused
on induction and maintenance of symptomatic responses, and little attention was paid to delay or even
prevention of disease progression.3 However, increasing
recognition of the concept of quality of life has led to
the evolution of treatment goals in IBD from clinical
response and remission (symptom control) toward
deep remission.4 In clinical studies, "deep remission"
means that treatment goals are evolving to encompass
not only symptomatic but also mucosal remission,5
which is defined as a Crohn's disease activating index
(CDAI) of <150 and complete mucosal healing.6
Abstract
OBJECTIVE: This article investigates the methods
of achieving deep remission of inflammatory bowel
disease (IBD).
METHODS: Increasing recognition of the concept
of quality of care is contributing to the evolution of
treatment goals in patients with IBD from clinical response and remission (symptom control) toward
deep remission. A change in the treatment goal requires a change in the treatment strategy. Optimization of conventional therapy, early treatment,
use of the Lemann score, performance of double-balloon endoscopy, treatment using Traditional
Chinese Medicine, and good communication between physicians and patients are needed to attain
deep remission.
RESULTS: The above-mentioned methods can help
to achieve deep remission.
CONCLUSION: Using the above methods, it will be
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This paper explores the treatment changes that have developed with the evolution of the goals of IBD therapy
and discusses the treatment methods necessary to reach
the goal of deep remission.
However, translating these goals into everyday practice
requires the implantation of optimized treatment strategies and ongoing monitoring of treatment outcomes.12
In addition, precise definition of the goals themselves
is required, and the long-term benefits associated with
their achievement need to be studied. Furthermore, although effective treatments are available, there remain
many uncertainties about how best to use them.13
EVOLUTION OF TREATMENT GOALS
IN IBD
The evolution of treatment goals in patients with IBD
is potentially changing the course of the disease, the expectations of patients and healthcare professionals, and
the development of treatment plans. Twenty years ago,
treatment methods for IBD were based on the symptoms of the patient, and the point of view that early
treatment would lead to long-term maintenance of remission was put forward.7 This point of view has become the standard of treatment in the form of induction of remission and its subsequent maintenance. The
provision of personalized medicine is now becoming
possible through, for example, a better understanding
of pharmacogenetics and therapeutic drug monitoring.8 In the future, treatment will be increasingly determined and optimized according to biotypes based on
genetics, serology, proteomics, metabolomics, individual microbiology, etc.9 In addition, treatment goals have
evolved toward mucosal healing with establishment
and maintenance of deep remission. It is hoped that
achieving these goals will lead to improvements in clinical outcomes, including quality of life, and reductions
in disease-related complications and costs of surgery
and hospitalization. Future goals may include avoidance of corticosteroids, prevention of extraintestinal
complications, and decreased treatment costs.10
Changing treatment goals requires variations in treatment strategies. In conventional approaches, immunomodulators are used with a bottom-up strategy based
on clinical outcomes. At present, the aims include induction and maintenance of clinical remission, prevention of disease development and complications, optimization of surgical outcomes, and prevention of postoperative recurrence. Future approaches are likely to involve personalized treatments based on the patient's
prognosis as determined using biological predictors of
response. Future goals will be to increase therapeutic effects, decrease treatment costs, and prevent disease.
Optimization of conventional therapy
Corticosteroids and immunomodulators have been
used in the treatment of IBD for decades, and their effectiveness is highlighted by the fact that they are recommended by national and international guidelines.14
However, these agents also have some disadvantages.
Although corticosteroids are very effective, they are not
able to maintain remission, and their side effect profile
makes their long-term use inappropriate. In addition,
the slow action of immunomodulators may not be adequate to induce remission, and their long-term ability
to modify disease has recently been questioned.
Despite these shortcomings, corticosteroids and immunomodulators have been widely used in the treatment
of IBD for many years. However, high-quality evidence
to guide their precise use in terms of dosage, mode of
administration, and duration of therapy is limited.15
High-quality studies showing that corticosteroids effectively induced clinical remission in patients with IBD
were published more than 30 years ago, and the efficacy of corticosteroids in IBD has been confirmed in Cochrane systematic reviews of controlled studies.16 However, once remission has been achieved, the goal is to
maintain steroid-free remission. Despite inducing remission in most patients, a prolonged response to corticosteroids is observed in less than half of all patients.17
Importantly, corticosteroids are associated with substantial toxicity and should not be continued long-term.
Thus, corticosteroids alone are inadequate for achieving the proposed treatment goal of deep remission.
They should normally be supplemented and ultimately
replaced by immunomodulators early in the treatment
course.18
Early treatment
The clinical features of IBD have changed in recent
years, with a decreasing frequency of a purely inflammatory response and an increasing frequency of a penetrating disease leading to the need for surgery. Accordingly, to change the course of the disease, disease-modifying treatments must be prescribed early in the course
of IBD before complications occur.19
There is now increasing clinical evidence to support
the hypothesis that early treatment improves clinical
outcomes in patients with IBD. Recent studies have also demonstrated that early treatment with anti-TNF
therapy is associated with sustained steroid-free remission and complete mucosal healing.20
However, the identification of patients with early IBD
in clinical practice remains a challenge because no for-
HOW TO IMPROVE THE
MANAGEMENT OF IBD TO ACHIEVE
DEEP REMISSION
Advances in drug development have provided highly effective treatments to prevent bowel structure damage
in patients with IBD, making deep remission a realistic
goal.11 In fact, anti-TNF therapy achieved deep remission in a randomized placebo-controlled clinical study,
which also indicates that deep remission is closely associated with a significant increase in quality of life and a
significant decrease in the need for hospitalization.
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mal definition exists. An international consensus has
been established to develop a formal definition of early
IBD. The agreed-upon definition is a disease duration
of <18 months in the absence of the use of disease-modifying agents.21 General acceptance of such a
definition will help establish the widespread use of an
optimized treatment strategy.
the last 10 to 15 years.24,25 Satisfactory results and positive effects of both acupuncture and acupuncture combined with Chinese herbal medicine decoctions have
been reported.26
According to TCM theory, spleen "damp-heat", which
is present in many patients with mild to moderate
IBD, cannot strongly promote blood circulation, easily
resulting in "blood stasis". Combined wind and dampness is found to adversely interfere with "Yang Qi", inducing blood stagnation and resulting in thrombosis
and stagnant cold-dampness.27
The TCM treatment principles for IBD are regulation
of Qi activity, promotion and improvement of blood
circulation, and invigoration of the spleen. TCM therapy has shown definite effectiveness. At the same time,
because TCM methods involve a long-term treatment
course, they greatly contribute to achieving the aim of
deep remission. In addition, if patients have erosions
that are confined to the colon, even the left-sided colon and mainly ulcerative colitis, treatment comprising
enemas or Chinese medicine suppositories would be
adopted. Such treatments can not only directly reach
the erosions, but also have long-term effects. In TCM,
they are now regarded as important complementary
methods for patients with IBD.
New indices in IBD management
Several assessment tools are available for evaluating
IBD symptoms, including the CDAI and Harvey-Bradshaw index, but these are often not used routinely in
clinical practice. However, the Lemann score is clinically useful and can reflect both the extent and severity of
digestive damage.22 To assess the extent of damage, the
digestive tract is considered to be divided into segments: the upper tract comprises 3 segments, the small
bowel comprises up to 20 segments, the colon and rectum comprise 6 segments, and the anus is considered
to be 1 segment.
As a first step in assessing the severity of damage, each
segment is evaluated separately for strictures, penetrating lesions, and a history of surgery or other procedures. Each section is graded from no damage to the
most severe damage corresponding to resection, and
based on this evaluation, a score from 0 to 10 is attributed to each segment.
In the second step, the score per organ is calculated,
which is the sum of the scores in all segments in the organ. Thus, the score per organ would be 0 to 30 for
the upper tract, 0 to 200 for the small bowel, 0 to 60
for the colon/rectum, and 0 to 10 for the anus.
Finally, the scores obtained for each organ are summed
to give an overall score for the entire digestive tract.
The Lemann score is independent of the diagnostic
technique used and allows patients to be assessed at different clinical stages regardless of surgical history or
whether they have limited or extensive disease.
Good communication between physicians and
patients
Good communication between physician and patients
is a cornerstone of effective disease management.28 After diagnosis of IBD, patients are likely to feel great uncertainty about their future. They may be concerned
about the impact of the disease and its treatment on
their daily life, employment prospects, ability to have
children, and later need for hospitalization and surgery.
By proactively discussing these issues, physicians and
the patients can begin to build confidence and establish an open and long-lasting relationship of trust.
Clear communication regarding the benefits and risks
of alternative management strategies and therapeutic
options is essential throughout the physician-patient relationship. However, physicians must keep in mind
that the management goals that are important to the
patient and the benefits or risks assessed by the patient
may differ from their own. To help reconcile the two
perspectives, the physician must clearly communicate
issues such as the rationale for a long-term management plan, the impact of disease progression, steroid
dependence, common and rare potential complications
of surgery, etc. At every decision point, the potential
risk of the treatment (development of complications,
need for surgery, and nutritional problems) must be
carefully balanced against those of overtreatment (anti-TNF-induced toxicity and potential impact on quality of life).
Role of endoscopy in daily clinical practice
Endoscopy plays a key role in the monitoring of IBD.
It allows for assessment of the extent and severity of
the disease, aids treatment decisions, and detects signs
of progression.
Double-balloon endoscopy (DBE) allows for complete
examination of the small bowel, which is important for
determining the extent of mucosal healing.23 Furthermore, it may also be used for biopsies or therapeutic interventions (such as balloon dilatation of strictures)
during DBE. This means that DBE may offer an alternative to surgery for some patients. DBE has been successfully used to dilate strictures, while endoscopy does
not have this function.
Use of Traditional Chinese Medicine
Acupuncture, a popular procedure in Traditional Chinese Medicine (TCM), has a long history of medical
treatment in China and other Asian countries. It has
been increasingly performed as a complementary and
alternative medical therapy for patients with IBD in
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CONCLUSION
IBD is characterized by sustained inflammation that
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may affect any part of the gastrointestinal tract. Chronic uncontrolled inflammation can lead to the development of complications such as stenosis and fistulae, resulting in irreversible structural bowel damage that is
not amenable to medical therapy.29 Such damage is often associated with the need for surgical removal of
bowel segments. Even during clinical remission, subclinical inflammation may persist and is largely unrecognized, increasing the risk of complications. Treating
physicians must recognize the disconnect between
symptoms and the presence of inflammation, and periodic evaluation of disease activity should be routinely
conducted. It is hoped that complete control of inflammation, timely use of appropriate therapy, strict control of complications, and minimization of bowel damage will change the course of the disease, improve prognoses, and increase the quality of life of affected patients.
12
13
14
15
16
17
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