Mucosal healing: impact on the natural course or therapeutic strategies

The treatment with anti-TNF in inflammatory bowel disease (IBD) has shown a much higher rate of mucosal healing (MH) compared to previous treatments. As MH after treatment also seemed to predict a positive outcome of disease regarding long-term outcome and reduced economic burden on the healthcare system, the question was if MH would have an impact on both the natural course of disease and treatment strategy. AREAS OF EXPERIENCE: Literature search includes population-based cohort studies, such as the Norwegian IBSEN study, and hospital-based studies, such as the GETAID study from France, both referring to MH in prospective follow-up studies of treatment prior to the introduction of biologics. Additionally, experience is based on short- and long-term efficacy studies with anti-TNF treatment, especially infliximab. From all studies, predictability of MH on long-term outcome of disease, including surgery and hospitalization, was assessed.

MH predicts a generally favorable outcome of disease based on all types of treatment strategies, except glucocorticosteroids, and is related to treatment efficacy-reduced frequency of surgery and hospitalizations. Scheduled treatment with anti-TNF is superior to episodic treatment and a top-down strategy has a favorable effect on healing. A limitation of MH as a universal marker is the fact that less than 50% of patients with a clinical effect of treatment acquire complete healing and MH appears in less than 30% of all patients on anti-TNF.

MH has become a valuable marker of efficacy in IBD, predicting a favorable disease outcome. In the future, additional markers of healing are expected to be combined with today's endoscopic and histologic assessments.