Point-counterpoint: Are we overtreating patients with mild ulcerative colitis?
Point-counterpoint: Are we overtreating patients with mild ulcerative colitis?
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点对点：我们是否过度治疗轻度溃疡性结肠炎患者？
DOI：
10.1016/j.crohns.2013.07.003
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发表时间：
2014
期刊：
影响因子：
--
通讯作者：
Saini,SameerD
中科院分区：
文献类型：
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作者：
Waljee,AkbarK;Stidham,RyanW;Higgins,PeterDR;Vijan,Sandeep;Saini,SameerD
背景在过去的几十年里，我们已经看到了用于治疗炎症性肠病（IBD）的药物的数量和种类的急剧增加。治疗选择的增加是专门研究人员，患者倡导团体和制药行业共同努力的结果。因此，IBD患者现在比以往任何时候都有更多的治疗选择。但与大多数慢性疾病一样，IBD具有广泛的疾病严重程度。为了概念上的简单，我们可以根据疾病的自然史是有利的还是不利的来对这个谱进行二分法。在自然史不利的重度疾病患者中（例如，糖皮质激素难治性溃疡性全结肠炎），通常需要积极的全身免疫调节治疗。理想情况下，这些患者的高质量护理应导致症状的解决，延长缓解期，并避免长期疾病并发症。另一方面，在患有静止期或轻度疾病的个体中，即使没有治疗也具有良好的预后，长期维持治疗的益处不太确定。虽然很难精确估计预后良好的轻度疾病的患病率，但这些患者在临床实践中很常见。目前的指南建议这些患者接受连续5-阿萨治疗，目的是预防疾病发作并可能减少长期并发症。1，2但结肠切除术或结直肠癌（CRC）等并发症在该人群中极为罕见，并且（如下所述）现有数据未能显示连续5-阿萨维持治疗的明显获益。在这篇文章中，我们将研究长期连续使用5-阿萨治疗轻度UC患者的利弊。由于这种治疗的益处可能很小，而且我们精确量化这些益处的能力有限，我们提出了一种更加共享，知情和个性化的方法来明确承认这些不确定性。
BackgroundOver the last several decades, we have seen a dramatic increase in the number and variety of medications available for the treatment of inflammatory bowel disease (IBD). This increase in therapeutic options is the result of concerted and coordinated efforts by dedicated researchers, patient advocacy groups, and the pharmaceutical industry. As a result, patients with IBD now have more options for treatment than ever before. But like most chronic diseases, IBD has a wide spectrum of disease severity. For conceptual simplicity, we can dichotomize this spectrum according to whether the natural history of the disease is favorable or unfavorable. In individuals with severe disease, where the natural history is unfavorable (eg, ulcerative pancolitis that is refractory to corticosteroids), aggressive systemic immunomodulatory treatment is often needed. High-quality care in these patients should ideally lead to resolution of symptoms, a prolonged remission, and avoidance of long-term disease complications. On the other hand, in individuals with established quiescent or mild disease, which has a favorable prognosis even without therapy, the benefits of long-term maintenance treatment are less certain. Though it is difficult to precisely estimate the prevalence of mild disease with a favorable prognosis, these patients are common in clinical practice. Current guidelines recommend that these patients be treated with continuous 5-ASA therapy, with the goal of preventing disease flares and potentially reducing long-term complications. 1, 2 But complications such as colectomy or colorectal cancer (CRC) are exceedingly uncommon in this population, and (as detailed below) available data have failed to show a clear benefit from continuous 5-ASA maintenance therapy. In this piece, we will examine the pros and cons of long-term, continuous 5-ASA use in patients with established mild UC. Because the benefits of such therapy are likely to be small, and our ability to precisely quantify these benefits is limited, we propose a more shared, informed, and individualized approach to decision-making in these patients that explicitly acknowledges these uncertainties.