IBD scoring systems - cag-acg.org · Use of IBD scores within clinical trials (UC) • Used for objecGve assessment of endoscopic improvement • Interrater agreement poor between

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



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


Abbvie Research support

Name: Dr. Mallory Chavannes


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


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)


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)


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


Case 2 (UC)

•  18yoMwithUCwhohasbeenoninfliximabsincehisdiagnosis2yearsago.Receives7.5mg/Kgq5weeks.Symptomsaremanageablewith3semi-formedBMperdayandnobloodandaCRP=6.RecentfecalcalprotecGnimprovedfrom1800to965.Colonoscopytoreassessdiseaseshowsthis…


-  Erythema-  Lossofvascularmarkings

-  Mucopus

-  Granularity

-  ConGnuousinflammaGon

HowsevereistheinflammaGon?Whatmayoendoscopicscorewoulditbe?

Using the MES

MES2


Case 3 (CD)

•  40yopaGentknowtohaveileocolonicCDfor2years.Onadalimumabmonotherapy40mgq1wkforthepastyear(noprevioususeofinfliximab).Worseningsymptomsofdiarrheaandweightlossoverthelast6weeks.CRP15.FC700.YouscopetoreassessdiseaseacGvityandseethis…


-  Deepulcers

-  Linear/serpiginousulcers

-  Erythema

-  Edema

-  Aphthousulcers

-  PatchyinflammaGon

HowsevereistheinflammaGon?WhatSES-CDscorewoulditbe?

Whatpercentofthesurfaceisulcerated?Whatpercentofthesurfaceisaffected?

Using the SES-CD

SES-CD7-8


Case 4 CD

•  40yopaGentknownfora10yearhistoryofileocolonicCrohn’sdisease.Compliantwithazathioprinetherapyandachievinggoodlevels(6TG330).Worseningsymptomsoverthepastfewmonths.Hgb90,Plt713,WBC4.2,lymphocytes0.3.CRP30.FC1070.2-3loosestoolsperday,withnewonsetbleedingbutmaintainingweight/appeGte.Youscopeandfind…



-  Deeplinearulcers

-  Edema

-  Possiblenarrowingofthelumen

-  Scaderedaphthousulcersandmucopus


Using the SES-CD

SES-CD9-10


Case 5 CD

•  20yopaGenthashad5yearsofileocolonicCD,oninfliximabfor2years,currentlyon5mg/kgq6wk.Recentincreaseinfrequencyofbowelmovements,withoccasionaldiarrhea.Normalbloodwork.FC335.Oncolonoscopy,thecolonlookedlikethis…



-  Erythema

-  Aphthousulcers


Using the SES-CD

SES-CD4-5


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


Using the UCEIS

UCEIS3-4


Using the CDEIS

Feature Scoring

DeepulceraGons 0=no,12=yes

SuperficialulceraGons 0=no,6=yes

Surfaceinvolvedindisease 1pointperevery10%

SurfaceinvolvedinulceraGons 1pointperevery10%

Ulceratedstenosisornon-ulceratedstenosis Add3points

CDEIS24-25


Using the CDEIS

Feature Scoring






CDEIS10-11


Using the CDEIS

Feature Scoring






CDEIS33


Resources

•  IGIBDscoresapp•  IBDScoresapp• CAG/AbbvieSEEMLI:StandardizingtheEndoscopicEvaluaGonofMucosalLesionsinIBD:www.seemli.ca

PleasedownloadtheCDDW™apptocompletethesessionevaluaGonandtoreceiveyourcerGficateofadendance.

Evaluation and Certificate of Attendance

Documents

IBD scoring systems - cag-acg.org · Use of IBD scores within clinical trials (UC) • Used for objecGve assessment of endoscopic improvement • Interrater agreement poor between