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Selective Drug-Free Active Surveillance in Ulcerative Colitis: Biomarker-Guided, Patient-Centered Approach.

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Selected ulcerative colitis (UC) patients in remission may stop 5-aminosalicylic acid (5-ASA) therapy. Drug-free active surveillance (DFAS) using biomarkers can monitor for subclinical inflammation, allowing for personalized care and reduced medication reliance.

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Area of Science:

  • Gastroenterology
  • Clinical Medicine
  • Inflammatory Bowel Disease Research

Background:

  • Ulcerative colitis (UC) management traditionally involves long-term 5-aminosalicylic acid (5-ASA).
  • Real-world data suggest selected low-risk UC patients in deep remission may not need continuous 5-ASA therapy.
  • Symptom assessment alone can be unreliable due to factors like irritable bowel syndrome overlap.

Purpose of the Study:

  • To define the clinical rationale for drug-free active surveillance (DFAS) in UC patients.
  • To establish criteria for selecting appropriate candidates for DFAS after 5-ASA discontinuation.
  • To propose a biomarker-guided algorithm for DFAS implementation and outline a research agenda.

Main Methods:

  • Review of randomized trials and real-world experience with 5-ASA in UC.
  • Evaluation of noninvasive biomarkers (fecal calprotectin, serum leucine-rich alpha-2 glycoprotein) for detecting subclinical inflammation.
  • Integration of patient-reported outcomes, mental health assessments, and shared decision-making for patient-centered care.

Main Results:

  • DFAS is feasible in selected UC patients, guided by noninvasive biomarkers to detect subclinical inflammation.
  • Biomarker monitoring reduces the need for frequent colonoscopies, enhancing DFAS acceptability.
  • Prioritizing endoscopic/histologic remission, stable biomarkers, and psychosocial well-being aids candidate selection.

Conclusions:

  • DFAS offers a patient-centered approach for selected low-risk UC patients, reducing long-term medication.
  • Structured surveillance with predefined relapse triggers and rescue pathways is crucial for DFAS safety.
  • Further research is needed to validate the safety, feasibility, and cost-effectiveness of DFAS in UC.