Treat to target or ‘treat to clear’ in inflammatory bowel diseases: one step further?

ABSTRACT

Introduction

Inflammatory bowel diseases (IBD) are chronic and progressive diseases. Long-term complications are demolitive surgery and colon-rectal cancer. A ‘treat to target’ strategy, in which the treatment aims to achieve objective outcomes, has already been introduced in the management of chronic conditions as rheumatic diseases. This approach is emerging as suitable for ulcerative colitis and Crohn’s disease. Targets are predefined therapeutic goals demonstrated to prevent end-organ dysfunction. An optimization or switch of therapy is considered depending on the target’s achievement, with regular monitoring.

Areas covered

According to the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) indications, mucosal healing and clinical remission are the main targets in IBDs. Histological remission is increasingly being considered as a novel target and has given rise to the new concept of ‘disease clearance’ which includes clinical, endoscopic and microscopic remission. We aim to review current evidence on the treat-to-target strategy in comparison to a stricter treat-to-clear in the IBD field.

Expert opinion

Prospective studies on treat-to-target algorithm are sparse; a treat-to-clear approach is desirable but far from adoption in the daily practice and clinical trials. The ultimate goals of a treat-to-clear strategy differ in UC and in CD, including histological healing and transmural healing, respectively.

KEYWORDS:

• Treat-to-target
• histological healing
• mucosal healing
• inflammatory bowel diseases
• remission
• long-term outcomes

Article highlights

• Targets are objective and measurable endpoints, tight control of therapeutic response through biomarkers (such as CRP and FC) is the key to successfully pursuing the treat-to-target management.

• The concept of ‘disease clearance’ has recently emerged in ulcerative colitis; disease clearance identifies a combination of symptomatic remission, endoscopic mucosal healing along with histological healing.

• A treat-to-clear model seems to be more applicable for UC patients that may benefit from validated histological scores for the assessment of microscopic response.

• Accuracy of cross-sectional imaging techniques (MRE and US) is high, consistent and comparable to endoscopic assessment. Trans-mural healing is a possible outcome-modifier of special interest in CD and could possibly be included in the concept of disease clearance.

Declaration of interest

S Danese has served as a speaker, consultant and advisory board member for Schering- Plough, AbbVie, MSD, UCB Pharma, Ferring, Cellerix, Millenium Takeda, Nycomed, Pharmacosmos, Actelion, Alphawasserman, Genentech, Grunenthal, Pfizer, Astra Zeneca, Novo Nordisk, Cosmo Pharmaceuticals, Vifor and Johnson & Johnson, Nikkiso Europe GMBH, Theravance. G Roda has served as speaker for Abbvie, Takeda and Pfizer. M Argollo has served as speaker, consultant and advisory board for Abbvie, Janssen, Takeda, Pfizer. LP Biroulet has served as a speaker, consultant and advisory board member for Merck, Abbvie, Janssen, Genentech, Mitsubishi, Ferring, Norgine, Tillots, Vifor, Hospira/Pfizer, Celltrion, Takeda, Biogaran, Boerhinger-Ingelheim, Lilly, HAC- Pharma, Index Pharmaceuticals, Amgen, Sandoz, For- ward Pharma GmbH, Celgene, Biogen, Lycera, Samsung Bioepis, Theravance. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.