Maarten Cozijnsen

143 Chapter 7 General discussion Endoscopic and symptomatic remission are primary treatment goals Endoscopic remission should be one of the primary goals for CD treatment, together with symptomatic remission. Literature clearly demonstrates less disease relapses and reduced complication rates when endoscopic remission is achieved. 8,18–20 The combination of both endoscopic and symptomatic remission is essential. Treating toward symptomatic remission only would leave the possibility open for subclinical, lingering inflammation, while treating toward endoscopic remission neglects the symptoms hindering patients. Experts of the Pediatric Inflammatory Bowel Disease Network (PIBDnet) and the pediatric committee of European Crohn’s and Colitis Organization (ECCO) agree that clinical trials including pediatric CD patients should use mucosal inflammation as endpoint of treatment effectiveness. 21,22 Besides in clinical trials, assessment of endoscopic remission should have an important place in routine clinical outcome measurement since it currently is the best measure of disease activity. One step further would be to make endoscopic remission the target of CD treatment. Currently, the treatment guideline – currently being revised - does not recommend to make endoscopic remission the target of treatment. 8 It states that the benefits and risks of intensifying treatment when patients are in clinical remission but not in endoscopic remission are still under debate. Recently, an open-label RCT demonstrated in adult CD patients that using high fecal calprotectin (≥250µg) and C-reactive protein (CRP; ≥5µg/L) versus only clinical disease activity (CDAI≥150) and steroid use as criteria for treatment intensification with anti-TNF treatment, improves the rate of endoscopic remission at one year follow-up. 25 Still an RCT is needed in pediatric CD to demonstrate the relative benefits and risks of treating towards endoscopic remission versus current treatment target in pediatric CD (relieve symptoms, optimize growth, and improve quality of life while minimizing drug toxicity). 8 Although endoscopic evaluation is the best way to assess endoscopic remission, it is invasive, costly and poses potential risks, including the requirement of anesthesia in children and bowel preparation. 26 Therefore, noninvasive measures of endoscopic remission are desirable for tight monitoring of CD patients. This is why we developed the MINI index ( Chapter 2 ). The MINI index identifies children with endoscopic remission with high sensitivity and specificity based on noninvasive parameters. Thereby it provides a means to tightly monitor endoscopic remission, in addition to using endoscopic evaluations. PIBDnet experts propose to use the MINI index as outcome measure in clinical trials in addition to endoscopy or when endoscopy is not feasible. 21 Currently, the accuracy of the MINI index is tested in adult CD patients, so that in the future one measure can be used regardless of patients’ age.