Why Clinical Remission is Not The Goal In IBD

The goal of treatment is the control of inflammation in the digestive tract

Sleep endoscopy
An endoscopy is an important tool in the treatment of IBD because a gastroenterologist can learn about the extend of any inflammation that is present. VOISIN/PHANIE / Getty Images

What does it mean to have remission from Crohn's disease or ulcerative colitis? For most patients with inflammatory bowel disease (IBD), and their physicians, achieving remission is the primary goal of treatment. Remission may come about after treatment with medications or after having surgery. In some cases it might come about pretty quickly, but for others it may take more time and trying therapy with one or more drugs and/or surgery.

According to the Crohn's and Colitis Foundation of America, during a typical year, about 50% of people with Crohn's disease will either be in remission or have mild disease and about 48% of people with ulcerative colitis will be in remission.

What Is Remission?

The term remission means different things to different people, including patients and physicians. This can present a little bit of a problem when talking about what remission means and how it can be achieved. For many years, patients were considered to be in remission if there were few or no symptoms of IBD. This usually meant that symptoms such as abdominal pain, diarrhea, or bloody stools were either significantly reduced or completely gone. 

As more is learned about IBD, however, it is increasingly being understood that remission is a broader concept than a reduction of symptoms. For patients, getting control of symptoms will be the most important factor in improving quality of life in the short-term.

However, there could be other processes still going on with the IBD even though certain symptoms, or even all symptoms, are gone. Some patients can still have IBD inflammation even though they feel better. Inflammation is the sign of IBD that has the potential to lead to more serious complications.

Different Types of Remission

Patients can learn more about their IBD by having a discussion about remission with a gastroenterologist. There isn't a consensus on the exact definition of remission in IBD. There are, however, several scoring tools that physicians might use to determine if a patient has achieved remission. Different gastroenterologists and IBD centers will use the criteria that they've found to be most appropriate, which means it can be difficult to make comparisons.

Some of the different types of remission include:

  • Biochemical remission: Laboratory tests done on the blood or the stool don't show any of the hallmark signs of IBD.
  • Clinical remission: When the symptoms of IBD have lessened to the point that they're mostly absent or gone. 
  • Endoscopic remission: No inflammation is seen during a test where the physician can see the lining of the digestive tract, such as a colonoscopy or a sigmoidoscopy
  • Histologic remission: This type of remission encompasses both endoscopic and clinical remission. When biopsies are taken and examined, for instance during a colonoscopy, no inflammation is seen. 
  • Surgical remission: Surgery can also bring about a time of remission for some people with IBD, when it results in little or no inflammation or symptoms. 

    Why Clinical Remission Might Not Be Enough

    Clinical remission is certainly important to patients because it means feeling better. The symptoms of IBD that can be so troublesome and lead to patients unable to socialize or go to work or school are mostly or totally absent. Even for some physicians, this might be an endpoint of treatment, but it's increasingly being understood that remission should include more than controlling symptoms. Getting to what's called "deep" remission is now the goal.

    The reason for this is that even when in clinical remission and going about life like normal, the IBD could still be causing inflammation in the digestive tract.

    Studies have shown that anywhere between 30% and 45% of patients with ulcerative colitis who are in clinical remission have inflammation that can be found during endoscopy. The problem with this is that the inflammation puts the patient at increased risk for various other poor outcomes. This residual inflammation is associated with a relapse of the ulcerative colitis, a higher risk of having surgery, and more long-term problems such as an increased risk of colon cancer.

    What If There's Still Inflammation?

    Having few or no symptoms is great for patients, but getting to deep remission that includes controlling inflammation is important for long-term health. When there's still inflammation present in the digestive system, a different type of treatment might be needed. Working with a gastroenterologist to determine what treatment might be needed next to not only continue the clinical remission but also to bring about endoscopic remission is vital. Some patients may feel that it is enough to have no IBD symptoms, but a goal of treatment should also be that the inflammation is gone. There's more of a chance of a good long-term outcome from the IBD when endoscopy and biopsy shows that there is no leftover inflammation in the digestive system.

    A Word From Verywell

    As physicians and scientists become smarter about what happens in the digestive system of people with IBD, the definitions of some terms are changing. Remission is one such term, because it used to mean a lack of symptoms, but now means so much more. In fact, remission has now been split into several subcategories. While IBD specialists don't necessarily all agree on one single definition of what remission is, it is becoming accepted that clinical remission is not enough for patients. People with IBD not only need their symptoms controlled, but also the inflammation that IBD causes, in order to reduce the risk of various complications. Patients are smart about IBD and can appreciate the nuances of the different types of remission and how to achieve the endoscopic remission that will lead to better outcomes.

    Sources:

    Crohn's and Colitis Foundation of America. "Facts about Inflammatory Bowel Diseases." CCFA.org. 1 May 2011. 

    Moss AC. "Residual Inflammation and Ulcerative Colitis in Remission." Gastroenterol Hepatol (N Y). 2014 Mar; 10: 181–183.

    Pineton de Chambrun G, Blanc P, Peyrin-Biroulet L. "Current evidence supporting mucosal healing and deep remission as important treatment goals for inflammatory bowel disease." Expert Rev Gastroenterol Hepatol. 2016 Aug;10:915-927.

    Reinink AR, Lee TC, Higgins PD. "Endoscopic Mucosal Healing Predicts Favorable Clinical Outcomes in Inflammatory Bowel Disease: A Meta-analysis." Inflamm Bowel Dis. 2016 Aug;22:1859-1869. 

    Zallot C, Peyrin-Biroulet L. "Deep remission in inflammatory bowel disease: looking beyond symptoms." Curr Gastroenterol Rep. 2013 Mar;15:315. 

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