AGA Recommends Noninvasive Biomarker Testing for Managing Ulcerative Colitis


Guidelines recommend testing for calprotectin and lactoferrin in stool samples and C-reactive protein in the blood.

Endoscopy has long been deemed the gold standard for monitoring disease activity and progression in ulcerative colitis (UC). However, this procedure is invasive, expensive, and often inconvenient for the patient.

A new evidence-based guideline by the American Gastroenterological Association (AGA), published in this month’s issue of Gastroenterology, recommends the use of noninvasive biomarkers as a first-line method for monitoring and managing UC. Specifically, AGA outlines the use of fecal calprotectin and fecal lactoferrin, obtained from stool samples, and serum C-reactive protein (CRP), obtained from blood samples. All are biomarkers that indicate the presence of inflammation. Calprotectin and lactoferrin are specific to inflammation in the gastrointestinal tract.

The new guideline delineates monitoring strategies for patients with active UC and those in symptomatic remission.

For patients in remission, AGA recommends the following:

  • Conduct interval biomarker monitoring every 6 to 12 months (preferably fecal biomarkers).
  • If biomarkers are within normal range, continue biomarker monitoring and avoid endoscopy.
  • If biomarkers are elevated, perform endoscopic assessment.

For patients with active UC, AGA makes the following recommendations:

  • Begin with biomarker testing.
  • If the patient has mild symptoms and normal or elevated biomarkers, perform endoscopy.
  • If the patient has moderate to severe symptoms and biomarkers are within normal range, perform endoscopy.
  • If the patient has moderate to severe symptoms and elevated biomarkers, adjust treatment, and avoid endoscopy.

The guideline promotes shared decision-making, allowing patients who are symptomatic to opt for or out of endoscopic assessment in certain situations. Clinicians can use the Clinical Decision Support Tool to guide them in the use of biomarkers to monitor their patients’ disease progression and manage treatment.

AGA notes that biomarker testing is a cost-effective alternative to endoscopy and advocates for insurance providers to cover the cost of the testing.

Ashwin Ananthakrishnan, M.B.B.S., M.P.H.

Ashwin Ananthakrishnan, M.B.B.S., M.P.H.

“Currently biomarkers are considered experimental by insurers,” said guideline author Ashwin N. Ananthakrishnan, M.B.B.S., M.P.H., of Massachusetts General Hospital, in a press release. “This guideline is a major step in showing the value of noninvasive biomarkers and the importance of insurers covering biomarker monitoring to improve patient satisfaction and clinical outcomes.”

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