Role of Biomarkers for the Management of Crohn’s Disease

Comment: Patients who place a higher value on avoiding the burden of biomarker testing, over a potentially higher risk of flare and disease progression caused by missing subclinical inflammation, may reasonably choose interval symptom-based monitoring.

Implementation considerations:
Interval biomarker monitoring may be performed every 6–12 mo in patients in symptomatic remission.
Biomarker-based monitoring may be particularly useful in patients w biomarkers have historically correlated with endoscopic disease activity

• The panel considered recent confirmation of endoscopic or radiologic remission to ideally have been within 3 y.
• Radiologic assessment of disease activity may be a reasonable alternative to endoscopic assessment for patients with predominantly small bowel involvement.

Implementation considerations:

• In patients with CD in sustained symptomatic remission but elevated biomarkers, repeat measurement of biomarkers (in 3–6 mo) may be a reasonable alternative to endoscopic (or radiologic) assessment, especially if the latter has been performed recently.
• Lack of normalization of biomarkers (or persistently elevated biomarkers) in patients whose symptoms recently resolved after initial treatment of symptomatically active CD, likely suggests active inflammation, and may warrant treatment adjustment, without need for endoscopic (or radiologic) evaluation.

• Interval biomarker assessment and treatment adjustment may be performed every 2–4 mo in patients being treated for active symptoms.
• After resolution of symptoms (and normalization of biomarkers), endoscopic (and/or radiologic) evaluation should be performed to rule out active inflammation, typically 6–12 mo after treatment initiation or adjustment. The patient may then transition to guidance for patients in symptomatic remission.

• Lack of normalization of biomarkers (or persistently elevated biomarkers) in patients whose symptoms partially improve after initial treatment of active CD, likely suggests active inflammation, and may warrant treatment adjustment, without need for endoscopic (or radiologic) evaluation.

Implementation considerations:

• Risk stratification schemes to classify patients’ risk of endoscopic recurrence after surgically induced remission are not well-defined. Risks factors typically associated with low risk of recurrence 6–12 mo after surgically induced remission include older age at surgery (older than 50 y), nonsmoking, long-standing disease (more than 10 y), and first surgery for a short segment of fibrostenotic disease (<10–20 cm). Risk factors typically associated with high risk of recurrence 6–12 mo after surgically-induced remission include two or more prior surgeries, penetrating or perianal disease, smoking, young age at surgery, with long segment of small bowel resection. However, these risk factors may not be additive.
• In patients at low baseline risk of recurrence, who are also receiving postoperative pharmacologic prophylaxis, fecal calprotectin <150 µg/g may also rule out endoscopic recurrence.
• Normal CRP in patients with asymptomatic CD in surgically induced remission is not able to rule out endoscopic recurrence accurately.
• There are limited data on ongoing biomarker monitoring alone in patients with CD in surgically induced remission. Colonoscopic evaluation may be warranted beyond 12 mo after surgery in patients when biomarker-based monitoring is being pursued.