Treat-to-Target in Pediatric Inflammatory Bowel Disease: What Does the Evidence Say?
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LEADING ARTICLE
Treat‑to‑Target in Pediatric Inflammatory Bowel Disease: What Does the Evidence Say? Giulia D’Arcangelo1 · Marina Aloi1
© Springer Nature Switzerland AG 2020
Abstract The traditional management of inflammatory bowel disease, based on treatment intensification guided by clinical activity alone, has been revised in the last 10 years and a treat-to-target approach has been proposed and is currently under evaluation as a disease-modifying strategy. Treat-to-target focuses on objective and scheduled measures to monitor intestinal damage, with consequent therapeutic adjustments in case of failure to achieve pre-defined targets. Identification of targets has been set out by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) committee in 2015. Mucosal healing is universally accepted as the main target both in Crohn’s disease and ulcerative colitis, given its proven association with better long-term outcomes than clinical remission alone. Equally important is to ensure patients’ clinical remission and improve patient-reported outcomes. Transmural healing (for Crohn’s disease) and histological remission (for ulcerative colitis), listed as adjunctive targets, are likely to become primary targets in the near future. The ultimate goal of this approach is to modify the natural history of inflammatory bowel diseases by trying to block bowel damage progression, with interventions in the pre-clinical stage. In this review, we will discuss the current recommended therapeutic targets, as well as those that are considered adjunctive targets, with a focus on the limited pediatric literature available. Prospective long-term trials are warranted in order to identify the most appropriate target for the pediatric population and its specific issues. Identification of reliable predictors of disease course, outcome, and response to treatment will help to individually adapt each step of this monitoring algorithm and consequent therapeutic decision.
1 Introduction In the last decade, we witnessed a paradigm shift in the management of inflammatory bowel disease (IBD), from the mere control of symptoms to the healing of mucosal inflammation (mucosal healing, MH), with the ultimate goal of modifying the natural history of these diseases. The socalled treat-to-target (T2T) approach, adapted from rheumatoid arthritis and other chronic diseases [1, 2], focuses on an objective measure and monitoring of the intestinal damage at predefined timepoints, with consequent therapeutic adjustments in case of failure [3]. Inflammatory bowel diseases are chronic disorders whose evolution is marked by the occurrence of complications, * Marina Aloi [email protected] 1
Department of Women’s and Children’s Health, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
progressive bowel damage, increased risk of cancer, and disability. Traditional management focused on treating clinical symptoms and has been demonstrated ineffective in modifying this dis
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