The American Gastroenterological Association (AGA) has published a new clinical practice guideline on the role of biomarkers in the management of Crohn’s Disease (CD). This guideline, led by Ashwin Ananthakrishnan, MD, is based on a systematic review of recent literature and includes 11 conditional recommendations.
The guideline emphasizes the importance of a treat-to-target strategy in inflammatory bowel disease management and acknowledges that subjective symptoms often poorly correlate with objective inflammation. Traditionally, objective assessment relied on endoscopy, but this guideline highlights that fecal and serum biomarkers can be crucial in assessing inflammation in CD patients in the right clinical scenarios.
Key insights from the guideline include:
- Biomarkers are not intended to replace endoscopy but to ensure optimal monitoring of patients, sometimes using biomarkers and other times endoscopy.
- Biomarkers are directly proportional to the burden of inflammation. However, in cases of small bowel disease or very proximal disease, biomarkers may not be as elevated, leading to false negatives.
- In the absence of symptoms, a normal biomarker (fecal calprotectin or serum C-reactive protein [CRP]) confidently confirms endoscopic remission. Conversely, in the presence of moderate to severe symptoms, an elevated biomarker strongly suggests active disease and can guide treatment escalation decisions.
The guideline also addresses specific scenarios, such as the use of biomarkers in patients with CD in symptomatic remission, those with symptomatically active CD, and patients in surgically induced remission. It provides cutoff levels for fecal calprotectin and CRP to rule out active inflammation and avoid routine endoscopic assessment.
This guideline is expected to make gastroenterologists more comfortable using biomarkers in CD management, understanding the scenarios where they perform well and where endoscopic assessment is still necessary. Future editions of the guideline may include additional biomarkers and insights on their serial measurement and combination with other tests like CT, MRI, and intestinal ultrasound.