Sunday, July 14, 2013

Sending up the Flare

Flares and IBD

What constitutes a flare in Crohn’s Disease and Ulcerative Colitis?  We use the term to mean any active state of the disease in which we are feeling less than optimal.  It is generally characterized by increased diarrhea, abdominal pain, and similar states of distress.  Because we are looking at evidence-based medicine, is there a clinical definition of a flare that we can use?  The best clinical definition is disease that is not in a state of remission.  Unfortunately, that simply shifts the need to accurately define remission.  There have been several attempts to quantify remission, with the most common being the Crohn’s Disease Activity Index (CDAI).

The CDAI was put forth in 1976 as a mechanism for quantifying the state of an individual’s disease.  By quantifying the disease through a rating of symptoms, the progression can be tracked and the efficacy of medication can be judged.  The CDAI provided a mix of both quantifiable, objective measures with subjective (though still quantified) evaluations.  The primary areas of the CDAI are as follows:

2 points for each liquid or soft stool from the past week.
5 points for level of severity (0-3) of abdominal pain each day for the past week
7 points for each level of general malaise (0-4) each day for the past week
20 points each for:
·         Arthritis
·         Eye inflammation
·         Ulcerations of the mouth, lips, or gums
·         Perianal disease
·         Fistulae
·         Fever during the past week
30 points for taking Lomotil or an opiate to control diarrhea
10 points for each level of abdominal mass present (0-5)
6 points for a Hematocrit of <0.47 in men and <0.42 in women   
1 points for every percentage point above/below expected weight

Any score about 150 for the CDAI is considered to be active disease, or a “flare”.(1)  The CDAI is still in use, but has several criticisms, a few of which include:

·         It does not include other blood tests, like CRP, that are associated with inflammation
·         The results of a colonoscopy, sigmoidoscopy, or endoscopy are not included (or any other imaging)
·         Some of the general well-being evaluations are overly subjective, and don’t include things like fatigue or depression
·         There are multiple ways to control diarrhea, and the presence or absence of taking a particular drug may be a poor measure
·         It is primarily focused on Crohn’s disease vice Ulcerative Colitis (though there is a correlation to UC scores and health)

As an alternative (or complement) to CDAI, the Inflammatory Bowel Disease Questionnaire (IBDQ) was developed.  The IBDQ is a copyrighted, 32 question assessment used to look at the quality of life issues impacting those with IBD.  Each question is provided a 1-7 scale, with one being the worst score and 7 being the best.  While not specific to detecting remission, the IBDQ is helpful in tracking patient quality of life over the course of time.  A short version of the IBDQ is available for patient self-use at, and there are multiple variants to the original IBDQ that have been proposed and are available in the research literature.(2)  Other IBD measures, such as the Simple Index of Crohn’s Disease Activity, are used in multiple research areas, generally for large patient population evaluations.(3) 

There is still room for improvement in creating special-purpose tools to identify flares.  The indices can quantify the state of the disease in an individual, but don’t take into account the “normal” baseline, making the identification of “flare” points difficult.  Because general IBD health is a gradient and not a binary status, no measure is likely to be perfect.  Hence the term “flare” has a fairly arbitrary usage as a non-clinical term meaning a currently poor state of health due to active disease.

Bottom Line

·         Flares are an active state of Crohn’s or Ulcerative Colitis where the patient is no longer in remission.
·         Tools such as the CDAI, SICDA, and IBDQ allow for objective tracking of disease progress over time.
·         There is room for improvement in most of the indices, and as new markers and correlations are identified they can be expected to be further modified to reflect the new research.

1.       Best, William R., Jack M. Becktel, John W. Singleton, and F. Kern Jr. "Development of a Crohn's disease activity index. National Cooperative Crohn's Disease Study." Gastroenterology 70, no. 3 (1976): 439.
2.       Guyatt, Gordon, Alba Mitchell, E. Jan Irvine, J. Singer, N. Williams, R. Goodacre, and C. Tompkins. "A new measure of health status for clinical trials in inflammatory bowel disease." Gastroenterology 96, no. 3 (1989): 804.

3.       Harvey, R. F., and J. M. Bradshaw. "A simple index of Crohn's-disease activity." Lancet 1, no. 8167 (1980): 514.

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