Ulcerative Colitis Selecting Patient Candidates for Infliximab Therapy

Ulcerative Colitis Selecting Patient Candidates for Infliximab Therapy

Panes Julian
European Gastroenterology Review 2007 - December 2007
Published: October 2008
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Ulcerative colitis (UC), a form of inflammatory bowel disease (IBD), is a chronic condition characterised by diffuse inflammation of the colonic mucosa. Although the exact aetiology of UC remains unknown, it has been hypothesised that genetic, environmental and immunological factors have contributory roles. 1–6 The diagnosis and classification of UC are based on well-established clinical, endoscopic and histological criteria. Clinical severity in UC is graded as mild, moderate or severe. In terms of disease extent, distal disease is defined as colitis confined to the rectum (proctitis) or rectum and sigmoid colon (proctosigmoiditis). More extensive disease due to proximal involvement is defined as left-sided colitis, extensive colitis or pancolitis.7,8 The disease course is generally intermittent, with patients experiencing relapses and remissions. A prospective investigation of UC patients to evaluate the relapse rate and the duration of remission in UC on maintenance treatment with the aminosalicylate mesalazine (also known as mesalamine) reveals that 52% of patients experience more than one relapse per year.9 Clinical symptoms associated with active disease, along with psychological distress, lead to patients experiencing significant impairment in quality of life.10

The current goal of medical management of UC is to induce and maintain remission and improve the patient’s quality of life. The choice of drug therapy is guided by the severity and extent of UC, as well as by disease course over time. Most patients are treated with pharmacotherapy, and those that fail undergo surgery. Therapy based on the use of corticosteroids to induce remission and mesalazine preparations for maintenance leave a clear gap that needs to be filled in terms of effective therapeutic agents. Therapeutic goals in IBD should include the reduction of inflammation, rapid induction of remission, sustained symptomatic remission and healing of the intestinal mucosa, reduction of steroid usage, reduction of the rate of hospitalisation and surgery, avoidance of complications and effective treatment of extra-intestinal manifestations. Altogether, achieving these goals will result in improving the quality of life of patients. Surgery is frequently advocated as a ‘cure’ for UC. However, surgery is not free of its own complications. Ileal pouch–anal anastomosis (IPAA) has become the standard of care for the 25% of patients with UC who ultimately require colectomy,11 but IPAA remains a technically difficult operation associated with significant morbidity.12 Bowel frequency may continue to be a problem, with median stool frequencies remaining at five per day and one at night, with some patients needing one or more additional surgeries.13 Finally, infertility is significantly higher in females who undergo IPAA surgery compared with females managed medically.14

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