From the AGA Journals

Ulcerative colitis is disabling over time


Key clinical point: Although usually mild to moderate in severity, ulcerative colitis is disabling over time.

Major finding: Cumulative risk of relapse was 70%-80% at 10 years.

Data source: A systematic review and analysis of 17 population-based cohorts.

Disclosures: Dr. Fumery disclosed support from the French Society of Gastroenterology, Abbvie, MSD, Takeda, and Ferring. Coinvestigators disclosed ties to numerous pharmaceutical companies.

Source: Fumery M et al. Clin Gastroenterol Hepatol. 2017 Jun 16. doi: 10.1016/j.cgh.2017.06.016.

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Tracking UC’s natural history

Understanding the natural history of ulcerative colitis (UC) is imperative especially in view of emerging therapies that could have the potential to alter the natural course of disease. Dr. Fumery and his colleagues are to be congratulated for conducting a comprehensive review of different inception cohorts across the world and evaluating different facets of the disease. They found that the majority of patients had a mild-moderate disease course, which was most active at the time of diagnosis. Approximately half the patients require UC-related hospitalization at some time during the course of their disease. Similarly, 50% of patients received corticosteroids, and while almost all patients with UC were treated with mesalamine within 1 year of diagnosis, 30%-40% are not on mesalamine long term. They also identified consistent predictors of poor prognosis, including young age at diagnosis, extensive disease, early need for corticosteroids, and elevated biochemical markers.

These results are reassuring because they reinforce the previous observations that roughly half the patients with UC have an uncomplicated disease course and that the first few years of disease are the most aggressive. A good indicator was that the proportion of patients receiving corticosteroids decreased over time. The disheartening news was that the long-term colectomy rates have generally remained stable over time.

Dr. Nabeel Khan is assistant professor clinical medicine at the University of Pennsylvania, Philadelphia

Dr. Nabeel Khan

The surprising aspect was the scarcity of data from North America; almost half the studies were from Scandinavian countries. There was also limited information on the impact of biologics and future research must be undertaken to evaluate their effect on the natural history of disease – especially the impact of early introduction among those who have poor prognostic features. This will go a long way in developing a personalized medicine approach in the management of UC.

Nabeel Khan, MD, is assistant professor of clinical medicine, University of Pennsylvania, Philadelphia, and director of gastroenterology, Philadelphia Veterans Affairs Medical Center. He has received research grants from Takeda, Luitpold, and Pfizer.



Between 70% and 80% of patients with ulcerative colitis relapsed within 10 years of diagnosis and 10%-15% had aggressive disease in a meta-analysis of 17 population-based cohorts spanning 1935 to 2016.

However, “contemporary population-based cohorts of patients diagnosed in the biologic era are lacking,” [and they] may inform us of the population-level impact of paradigm shifts in approach to ulcerative colitis management during the last decade, such as early use of disease-modifying biologic therapy and treat-to-target [strategies],” wrote Mathurin Fumery, MD, of the University of California San Diego, La Jolla. The report was published in Clinical Gastroenterology and Hepatology (2017 Jun 16. doi: 10.1016/j.cgh.2017.06.016).

Population-based observational cohort studies follow an entire group in a geographic area over an extended time, which better characterizes the true natural history of disease outside highly controlled settings of clinical trials, the reviewers noted. They searched MEDLINE for population-based longitudinal studies of adults with newly diagnosed ulcerative colitis, whose medical records were reviewed, and who were followed for at least a year. They identified 60 such studies of 17 cohorts that included 15,316 patients in southern and northern Europe, Australia, Israel, the United States, Canada, China, Hong Kong, Indonesia, Sri Lanka, Macau, Malaysia, Singapore, and Thailand.

Left-sided colitis was most common (median, 40%; interquartile range, 33%-45%) and about 10%-30% of patients had disease extension. Patients tended to have mild to moderate disease that was most active at diagnosis and subsequently alternated between remission and mild activity. However, nearly half of patients were hospitalized at some point because of ulcerative colitis, and about half of that subgroup was rehospitalized within 5 years. Furthermore, up to 15% of patients with ulcerative colitis underwent colectomy within 10 years, a risk that mucosal healing helped mitigate. Use of corticosteroids dropped over time as the prevalence of immunomodulators and anti–tumor necrosis factor therapy rose.

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