# Prediction of IBD Relapse



## Guest (Jul 14, 2003)

Excerpt from:Markers of Intestinal Inflammation as Predictors of Clinical Relapse in Patients With Quiescent IBDJ.A. Tibble, MRCP, MD, MSc, I. Bjarnason, DSc, MD, Department of Medicine, Guy's, Kings, and St. Thomas' School of Medicine and Dentistry, London, EnglandMedscape General Medicine 3(2), 2001. ï¿½ 2001 Medscape Posted 03/01/2001 ----------------------------------------------------"Fecal Calprotectin and Prediction of IBD RelapseUntil recently, the utility of measuring intestinal inflammation directly as a means of predicting relapse has not been assessed. Indium leukocyte scanning and quantitative fecal 111indium-labeled leukocyte excretion have been used for localization of disease and assessment of disease severity, respectively, in patients with IBD.[17,18] However, the exposure to radiation and the 4-day collection of stools make it an unsuitable method for outpatient monitoring of mucosal inflammatory activity.A recent study has demonstrated the usefulness of fecal calprotectin in predicting relapse of IBD.[19] Calprotectin, first isolated from granulocytes by Fagerhol and colleagues,[20] was initially termed "L1 protein," but subsequent to the identification of its calcium binding and antimicrobial properties, was renamed "calprotectin."[21] Within the neutrophil, calprotectin is found in the extra lysosomal cytosol, and constitutes up to 60% of the cytosolic protein fraction of these cells.[22] Calprotectin resists metabolic degradation by intestinal bacteria and is stable in stool for up to 1 week at room temperature.[23] Fecal calprotectin levels correlate significantly with histologic and endoscopic assessment of disease activity in ulcerative colitis (UC),[24] as well as with fecal alpha-1-antitrypsin levels and fecal excretion of 111indium-labeled white blood cells in patients with CD.[23, 25-27] In patients with clinically quiescent IBD (UC and CD), it was shown that fecal calprotectin levels greater than 50 mg/L could be used to predict the likelihood of clinical relapse of disease within a few months, with over 80% sensitivity.[19] Most patients with quiescent IBD have low-grade inflammation,[28] and it is suggested that symptomatic relapse occurs only when the inflammatory process reaches a critical intensity. Furthermore, if inflammation is a continuous process, it may be that direct assessment of the level of inflammatory activity can provide a quantitative presymptomatic measure of imminent clinical disease relapse.Clinical Implications of Predicting RelapseThe clinical implications of predicting which patients with IBD are likely to relapse are considerable. Such knowledge may allow targeted treatment at an earlier stage (with fewer side effects) to avert the relapse, as well as assessment of new therapeutic strategies for maintaining symptomatic remission.[29]Presently, early therapy to avert relapse is implemented with some degree of success via the rather indiscriminate use of sulfasalazine, 5-aminosalicylic acid, and azathioprine -- all of which are associated with side effects. However, the calprotectin methodology can offer guidance regarding whom to treat at this early stage and with what degree of intensity. Theoretically, such treatment should lead to a dramatic reduction in the frequency and severity of clinical relapses, with an associated improvement in the patient's quality of life.19.Tibble JA, Sigthorsson G, Bridger S, et al. Surrogate markers of intestinal inflammation are predictive of relapse in patients with quiescent inflammatory bowel disease. Gastroenterology. 2000;119:15-22. 20.Fagerhol MK, Dale I, Anderson I. Release and quantitation of a leucocyte derived protein (L1). Scan J Haematol. 1980;24:393-398. 21.Steinbakk M, Naess Andresen CF, Lingaas E, et al. Antimicrobial actions of calcium binding leucocyte L1 protein, calprotectin. Lancet. 1990;336:763-765. 22.Fagerhol MK, Andersson KB, Naess-Andresen CF, et al. Calprotectin (the L1 leukocyte protein). In: Smith VL, Dedman JR, eds. Stimulus Response Coupling: The Role of Intracellular Calcium-Binding Proteins. Boca Raton, Fla: CRC Press Inc; 1990:187-210. 23.Roseth AG, Fagerhol MK, Aadland E, et al. Assessment of the neutrophil dominating protein calprotectin in feces. A methodologic study. Scand J Gastroenterol. 1992;27:793-798. 24.Roseth AG, Aadland E, Jahnsen J, Raknerud N. Assessment of disease activity in ulcerative colitis by faecal calprotectin, a novel granulocyte marker protein. Digestion. 1997;58:176-180. 25.Tibble J, Teahon K, Thjodleifsson B, et al. A simple method for assessing intestinal inflammation in Crohn's disease. Gut. 2000;47:506-513. 26.Teahon K, Roseth A, Foster R, et al. Faecal calprotectin: a simple sensitive quantitative measure of intestinal inflammation in man. Gastroenterology. 1997;112:A1103. 27.Roseth AG, Schmidt PN, Fagerhol MK. Correlation between faecal excretion of indium-111-labelled granulocytes and calprotectin, a granulocyte marker protein, in patients with inflammatory bowel disease. Scand J Gastroenterol. 1999;34:50-54. 28.Saverymuttu SH. Clinical remission in Crohn's disease -- assessment using faecal Indium-111 granulocyte excretion. Digestion. 1986;33:74-79. "


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