ibd scoring systems - cag-acg.org · use of ibd scores within clinical trials (uc) • used for...
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IBD scoring systems
Lara Hart, MD FRCPC1,2
Talat Bessissow, MD FRCPC1
Mallory Chavannes, MD FRCPC3,4
1.McGillUniversityHealthCenter,MontrealQC;2.McMasterUniversityMedicalCenter,HamiltonON;3.St-Paul’sHospital,UniversityofBriGshColumbia,Vancouver,
BC;4.CHUSainteJusGne,UniversityofMontreal,MontrealQC
ObjecFves
Attheendofthisprogram,par2cipantsshouldbeableto…• DifferenGatebetweenthevariousIBDscoringsystems• UnderstandtheuGlityofthescoringsystemsandthegradingofseverityassociatedwitheachscore
• Usethescoringsystemsinendoscopyreports
Conflict of Interest Disclosure (over the past 24 months)
Commercial or Non-Profit Interest Relationship
Abbvie Research support
Name: Dr. Lara Hart
Conflict of Interest Disclosure (over the past 24 months)
Commercial or Non-Profit Interest Relationship
Abbvie Speaker, advisory board, research support
Janssen Speaker, research support
Takeda Speaker, advisory board
Ferring, Shire, Pendopharm, Merck
Speaker
Pfizer advisory board
Pentax Research support
Name: Dr. Talat Bessissow
Commercial or Non-Profit Interest Relationship
Abbvie Research support
Name: Dr. Mallory Chavannes
Conflict of Interest Disclosure (over the past 24 months)
X Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.)
X Communicator (as Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.)
Collaborator (as Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.)
X Leader (as Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.)
X Health Advocate (as Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.)
X Scholar (as Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.)
Professional (as Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.)
CanMEDS Roles Covered
Histologicalremission1,2
Mucosalhealing2,3
Biochemicalremission
Clinicalremission(steroid-Free)
Clinicalresponse
Therapeu?cobjec?veevolveastreatment
goalschange
EvoluFon of treatment targets
1. MolanderP,etal.JCrohnsColi/s2013.2. VillanacciV,etal.WorldJGastroenterol2013;19:968–78.3. LaharieD,etal.AlimentPharmTherap2013.
Symptom-free CRP 36 mg/L
Poor correlaFon symptoms – mucosal lesions
• Complete lack of correlation between CDAI (primarily symptom-based) and endoscopic inflammation
• Symptoms and signs of Crohn’s are neither sensitive nor specific
Modigliani R et al, Gastroenterology 1990
CorrelaFon symptoms –UC
Severe
0 20 40 60 80 100
Mild–moderate
Remission
Clinicalstate
Severe
0 20 40 60 80 100
Mild–moderate
Normal
SigmoidoscopicstateNoneMild–moderateSevere
TrueloveSC,etal.BrMedJ1956;1:1315–8
Histologicalfindings:Degreeofinflamma?on
CD Scoring Systems- CDEIS (1989)
MaryJYetal.Gut1989;30:983-9.
CD Scoring Systems- SES-CD (2004)
DapernoMetal.GIE2004;60(4):505-12.
InacGve=0–2;mild=3–6;moderate7–15;severe>16DefiniGonofMHvaries
Rutgeerts score (1990)
Sostegnietal.APT2003;17:11-7.
CD scoring systems
Scoringsystem Strength Weakness
CDEIS GoldstandardValidatedProspecGvestudyExtensivelyappliedinclinicaltrials
ComplexityNodefiniGonofMHNocorrelaGonwithCDAI
SES-CD ValidatedProspecGvestudySimplerthanCDEISCorrelatedwithCDEIS
NodefiniGonofMHNocorrelaGonwithCDAILessappliedinclinicaltrials
Rutgeertsscore ProspecGvestudyExtensivelyappliedinclinicaltrialsStrongprognosGcrelevance
NoformalvalidaGonOnlyinpost-operaGveileo-colonicresecGon
DapernoMetal.GIE2004;60(4):505-12.
UC Scoring systems Index Validated Variables Strengths Weaknesses
TrueloveandWibsEndoscopyIndex
No Granularity,hyperemia Precedence(firstreportedindex),butnoothermerit
Nodescrip?onofendoscopiclesionssointer-observervariabilityishigh
BaronIndex No Bleeding,vascularpabern,friability Easytouse Ulcera?onsnotincludedinscore;nodefini?onofmucosalhealing
Powell-TuckIndex No Bleeding Easytouse Ulcera?onnotincluded,nodefini?onofmucosalhealing
SutherlandIndex No Friability,bleeding,exuda?on Easytouse,overlapindescrip?vetermsfordifferentlevelsofac?vity
Subjec?ve,nodefini?onofmucosalhealing
MayoClinicIndex(endoscopicsubscore)
No Vascularpabern,erythema,friability,erosionsandulcera?on,bleeding
Easytouse,commonlyusedinclinicaltrials;overlapindescrip?vetermsusedfordifferentlevelsofac?vity
Novalidateddefini?onofmucosalhealing;Thetermminimalorslightfriabilityissubjec?veandleadstoinconsistentresults
RachmilewitzIndex No Granula?on,mucosaldamage,vascularpabern,vulnerabilityofmucosa(bleeding)
Nonereported Complexandsubjec?vedescrip?veterms
ModifiedBaronIndex No Vascularpabern,granularity,friability,bleeding,ulcera?on Easytouse Novalidateddefini?onofmucosalhealing
EndoscopicAc?vityIndex
No Sizeofulcers(4levels),depthofulcers(4levels),redness(3levels),bleeding(4levels),mucosaledema(4levels),mucosalexudate(3levels)
Closelycorrelatedwithclinicalac?vity.Comparabletootherindices.Usefulinseveredisease
MabsIndex No Granularity,bleeding,edema,ulcera?on Easytouse
Ulcera?veColi?sEndoscopicIndexofSeverity
Preliminary Vascularpabern(3levels),bleeding(4levels),ulcera?on(4levels)
Easytouse;Independentofclinicalsymptoms,accountsfor88%ofvaria?onbetweenobservers
Sensi?vitytochange,andmucosalhealingremainundefined
WalshA,etal.Gastrointest.EndoscClin.N.Am.2014;24:367–78.
UC Scoring systems- Mayo score (1987)
Mayoindex 0 1 2 3
Stoolfrequency Normal 1–2/day>normal 3–4/day>normal 5/day>normal
Rectalbleeding None Streaks Obvious Mostlyblood
Mucosa Normal Mildfriability Moderatefriability Spontaneousbleeding
Physician’sglobalassessment Normal Mild Moderate Severe
SchroederKW,etal.NEnglJMed1987;317:1625–9
0=inacGvedisease;1=milddisease;2=moderatedisease;3=severedisease.Mucosalhealing=0or1
UC Scoring systems- UCEIS (2012)
Descriptor(scoremostseverelesions)
Likertscaleanchorpoints Defini?on
Vascularpabern
Normal(1) Normalvascularpabernwitharborisa?onofcapillariesclearlydefined,orwithblurringorpatchylossofcapillarymargins
Patchyoblitera?on(2) Patchyoblitera?onofvascularpabern
Obliterated(3) Completeoblitera?onofvascularpabern
Bleeding
None(1) Novisibleblood
Mucosal(2) Somespotsorstreaksofcoagulatedbloodonthesurfaceofthemucosaaheadofthescope,whichcanbewashedaway
Luminalmild(3) Somefreeliquidbloodinthelumen
Luminalmoderateorsevere(4)
Frankbloodinthelumenaheadofendoscopeorvisibleoozingfrommucosaanerwashingintra-luminalblood,orvisibleoozingfromahaemorrhagicmucosa
Erosionsandulcers
None(1) Normalmucosa,novisibleerosionsorulcers
Erosions(2) Tiny(≤5mm)defectsinthemucosa,ofawhiteoryellowcolourwithaflatedge
Superficialulcer(3) Larger(>5mm)defectsinthemucosa,whicharediscretefibrin-coveredulcersincomparisonwitherosions,butremainsuperficial
Deepulcer(4) Deeperexcavateddefectsinthemucosa,withaslightlyraisededge
TravisSPL,etal.Gut2012;61:535–42
*ThresholdforMH,mild,moderateandseverediseasenotset
Scoring systems current use and reliability
Use of IBD scores within clinical trials (UC)
• UsedforobjecGveassessmentofendoscopicimprovement• Interrateragreementpoorbetweensitereaderandcentralreaders(ICC0.11to0.44)buthighbetweencentralreadersinUC
FeaganBG,etal.Gastroenterol2013;145(1):149-157
Use of IBD scores within clinical trials (CD)
• Bederinter-observercorrelaGonusingSES-CDandCDEIS
RutgeertsP,etal.Gastrointes/nalEndoscopy2016;83(1):188-197
• 129staffphysicians• 116treaGngadults(90%)• 78fromacademiccenters(60%)• 52performed>750colonoscopies/year(40%)• 38had>20yearsinpracGce(29%)
• 47fellowsreplies• 21werePGY-5(45%)• 13performed>400colonoscopies/year(28%)
Hartetal,Unpublisheddata
Canadian Survey: Do you see what I see
Use of IBD scores in clinical pracFce
Staff(n=129)
Residents(n=47)
All(n=176)
UsingSES-CD,n(%) 41(32) 26(55) 67(38)
UsingCDEIS,n(%) 3(2) 1(2) 4(2)
UsingMayo,n(%) 114(88) 42(89) 156(89)
ComfortusingCDscore,n(%) 65(50) 12(25) 77(44)
ComfortusingUCscore,n(%) 111(86) 37(79) 148(84)
Hartetal,Unpublisheddata
Why are physicians using scores ≤50% of Fme
Staff(n=129)
Residents(n=47)
All(n=176)
Notfamiliar,n(%) 10(8) 4(9) 14(8)
Forgettouse,n(%) 11(9) 2(4) 13(7)
Ratherdescribe,n(%) 37(29) 13(28) 50(28)
Timeconsuming,n(%) 2(2) 3(6) 5(3)
Toocomplicated,n(%) 9(7) 4(9) 13(7)
Nottrained,n(%) 1(1) 3(6) 4(2)
Hartetal,Unpublisheddata
Cases – pracFce using the scoring systems
Case 1 (UC)
• 20yopaGenthashad2yearhistoryofulceraGvecoliGs.Taking5ASA.Startedexperiencingprogressivelyworseningsymptoms;nowhaving8-12loosebloodybowelmovementsperday.FC>2100,stoolforinfecGousworkupnegaGve.CRP55,Hgb109,albumin33.Youdocolonoscopyandsee..
How would you describe the colon?
- Mucopus
- Erythema- Lossofvascularmarkings- UlceraGons
- Edema- Friability
HowsevereistheinflammaGon?Whatmayoendoscopicscorewoulditbe?
Using the MES
MES3
SchroederKW,etal.NEnglJMed1987;317:1625–9
Case 2 (UC)
• 18yoMwithUCwhohasbeenoninfliximabsincehisdiagnosis2yearsago.Receives7.5mg/Kgq5weeks.Symptomsaremanageablewith3semi-formedBMperdayandnobloodandaCRP=6.RecentfecalcalprotecGnimprovedfrom1800to965.Colonoscopytoreassessdiseaseshowsthis…
How would you describe the colon?
- Erythema- Lossofvascularmarkings
- Mucopus
- Granularity
- ConGnuousinflammaGon
HowsevereistheinflammaGon?Whatmayoendoscopicscorewoulditbe?
Using the MES
MES2
SchroederKW,etal.NEnglJMed1987;317:1625–9
Case 3 (CD)
• 40yopaGentknowtohaveileocolonicCDfor2years.Onadalimumabmonotherapy40mgq1wkforthepastyear(noprevioususeofinfliximab).Worseningsymptomsofdiarrheaandweightlossoverthelast6weeks.CRP15.FC700.YouscopetoreassessdiseaseacGvityandseethis…
How would you describe the colon?
- Deepulcers
- Linear/serpiginousulcers
- Erythema
- Edema
- Aphthousulcers
- PatchyinflammaGon
HowsevereistheinflammaGon?WhatSES-CDscorewoulditbe?
Whatpercentofthesurfaceisulcerated?Whatpercentofthesurfaceisaffected?
Using the SES-CD
SES-CD7-8
DapernoMetal.GIE2004;60(4):505-12.
Case 4 CD
• 40yopaGentknownfora10yearhistoryofileocolonicCrohn’sdisease.Compliantwithazathioprinetherapyandachievinggoodlevels(6TG330).Worseningsymptomsoverthepastfewmonths.Hgb90,Plt713,WBC4.2,lymphocytes0.3.CRP30.FC1070.2-3loosestoolsperday,withnewonsetbleedingbutmaintainingweight/appeGte.Youscopeandfind…
How would you describe the colon?
HowsevereistheinflammaGon?WhatSES-CDscorewoulditbe?
- Deeplinearulcers
- Edema
- Possiblenarrowingofthelumen
- Scaderedaphthousulcersandmucopus
Whatpercentofthesurfaceisulcerated?Whatpercentofthesurfaceisaffected?
Using the SES-CD
SES-CD9-10
DapernoMetal.GIE2004;60(4):505-12.
Case 5 CD
• 20yopaGenthashad5yearsofileocolonicCD,oninfliximabfor2years,currentlyon5mg/kgq6wk.Recentincreaseinfrequencyofbowelmovements,withoccasionaldiarrhea.Normalbloodwork.FC335.Oncolonoscopy,thecolonlookedlikethis…
How would you describe the colon?
HowsevereistheinflammaGon?WhatSES-CDscorewoulditbe?
- Erythema
- Aphthousulcers
Whatpercentofthesurfaceisulcerated?Whatpercentofthesurfaceisaffected?
Using the SES-CD
SES-CD4-5
DapernoMetal.GIE2004;60(4):505-12.
Case 6 (post-operaFve)
40yopaGenthashad5yearsofileocolonicCD.PresentedwithobstrucGvesymptomsandwasfoundtohavestrictureatTI.PaGenthadanileocecalresecGonandhadarepeatscopetoassessanastomosissite…
Using Rutgeerts’ score
Sostegnietal.APT2003;17:11-7.
Rutgeerts’i1
MES quick cases
MES1 MES0
MES2 MES3
SES-CD quick cases
SES-CD10-12
SES-CD7-9
SES-CD0
SES-CD4-6
Using the UCEIS
UCEIS7
TravisSPL,etal.Gut2012;61:535–42
Using the UCEIS
UCEIS3-4
TravisSPL,etal.Gut2012;61:535–42
Using the CDEIS
Feature Scoring
DeepulceraGons 0=no,12=yes
SuperficialulceraGons 0=no,6=yes
Surfaceinvolvedindisease 1pointperevery10%
SurfaceinvolvedinulceraGons 1pointperevery10%
Ulceratedstenosisornon-ulceratedstenosis Add3points
CDEIS24-25
MaryJYetal.Gut1989;30:983-9.
Using the CDEIS
Feature Scoring
DeepulceraGons 0=no,12=yes
SuperficialulceraGons 0=no,6=yes
Surfaceinvolvedindisease 1pointperevery10%
SurfaceinvolvedinulceraGons 1pointperevery10%
Ulceratedstenosisornon-ulceratedstenosis Add3points
CDEIS10-11
MaryJYetal.Gut1989;30:983-9.
Using the CDEIS
Feature Scoring
DeepulceraGons 0=no,12=yes
SuperficialulceraGons 0=no,6=yes
Surfaceinvolvedindisease 1pointperevery10%
SurfaceinvolvedinulceraGons 1pointperevery10%
Ulceratedstenosisornon-ulceratedstenosis Add3points
CDEIS33
MaryJYetal.Gut1989;30:983-9.
Resources
• IGIBDscoresapp• IBDScoresapp• CAG/AbbvieSEEMLI:StandardizingtheEndoscopicEvaluaGonofMucosalLesionsinIBD:www.seemli.ca
PleasedownloadtheCDDW™apptocompletethesessionevaluaGonandtoreceiveyourcerGficateofadendance.
Evaluation and Certificate of Attendance