Fecal calprotectin-guided treatment escalation strategy enhances disease clearance in ulcerative colitis

INTRODUCTION: Disease clearance may represent the ultimate treatment target in ulcerative colitis, but is seldom achieved in clinical practice. A treatment escalation strategy based on fecal calprotectin may potentially improve these results. METHODS: Case cohort study including 108 ulcerative colitis patients with severe endoscopic activity at baseline (Mayo endoscopic subscore = 3) and a follow-up endoscopy with histologic assessment. For each elevated fecal calprotectin (≥250 μg/g) between endoscopic evaluations, we identified any adjustment of medical treatment performed. The ratio of treatment escalation per elevated fecal calprotectin (Te/eFc) was correlated with disease clearance rates at the follow-up endoscopic evaluation. In addition, we compared the rates of negative outcomes (clinical relapse, treatment discontinuation, surgery, and colorectal cancer) in patients with and without disease clearance. RESULTS: Thirty-three (30.5%) patients reached disease clearance over a median follow-up of 21.5 months [interquartile range (IQR): 15-40 months]. Quartile analysis demonstrated that a ratio Te/eFc greater than 50% resulted in higher rates of disease clearance compared with a ratio Te/eFc less than or equal to 50% (51.5 vs. 20.0%; P = 0.001). In multivariate analysis, a ratio Te/eFc greater than 50% was independently associated with disease clearance (odds ratio: 4.47, 95% confidence interval: 1.79-11.15, P = 0.001). Patients with disease clearance presented lower chances of reaching any negative outcome (37.5 vs. 67.1%; P = 0.006). CONCLUSION: A Te/eFc greater than 50% improved the chances of obtaining disease clearance in ulcerative colitis. Disease clearance is associated with better long-term outcomes.