How rapidly should remission be achieved?

The major goal of therapy in inflammatory bowel disease is to induce remission. Remission has multiple definitions - clinical remission, where the patient's symptoms have remitted, and endoscopic remission, in which there has been complete mucosal healing. Mucosal healing is a harder endpoint of remission but may be more difficult to achieve. In clinical trials we are forced to use activity indices such as the Crohn's disease activity index that may not completely reflect the endoscopic and histologic state of the bowel. Ideally we would like to see remission as quickly as possible to improve patient quality of life. The time to remission varies between different therapeutic approaches. Steroids tend to have a rapid clinical effect with remission seen in some patients as early as two weeks. In early anti-TNF trials, a single dose of infliximab lead to 27% remission at two weeks compared to 4% of placebo patients. Adalimumab and certolizumab have similar reports of early induction of remission. Mesalamine in Crohn's disease has inconsistent and delayed remission rates, whereas in ulcerative colitis, response and remission rates are more consistent in the three-week time frame. Azathioprine and 6-mercaptopurine have delayed onset of action but may induce remission as early as six weeks if dosing is optimized. In this presentation induction of clinical remission and mucosal healing in Crohn's disease and ulcerative colitis will be discussed. The impact of early remission on disease course will also be reviewed.