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Therapeutic interventions in IBD should alleviate patient symptoms and modify long-term disease outcomes. This second target is hard to demonstrate within the context of typical observational or interventional studies due to problems of sample size and duration of follow-up. Instead, there has been considerable focus on the assessment of mucosal inflammation using validated scoring systems in both Crohn’s disease (CD)1 2 and UC.3 4 Achievement of endoscopic healing correlates with avoidance of long-term disease complications in both CD and UC,5 6 and is an established therapeutic target in addition to the achievement of clinical remission.7
For these reasons, data on endoscopic outcomes are now required by regulatory agencies for any registration trial.8 In addition, endoscopic outcome data may be used in earlier phase trials to guide decisions about further asset development, adding biological context to clinical data.9 Interventions which lead to improvements in symptom scores may not demonstrate improvements in endoscopic outcomes and this additional information may inform or limit placement in treatment paradigms.10 11 Furthermore, the use of endoscopic activity as an inclusion criterion for clinical trials can reduce the high placebo response rates previously reported in trials reliant purely on clinical inclusion criteria, which may mask efficacy signals.12
Key barriers to use of endoscopy in clinical trials include patient acceptability.13 Additionally, there is a need for blinded central reading of all trial endoscopies to ensure standardisation and avoid inadvertent introduction of investigator bias: local endoscopy reads are typically less reliable than blinded central reading by a recognised expert reader.14 Reliance on local readers may even lead to critical errors in trial interpretation.15 Furthermore, use of central readers alone does not completely mitigate against errors of endoscopy reading that may lead to false conclusions about novel interventions,16 …
Contributors Study conception and design was done by TR, HP, WQ, JL, MP and NAK. Study was conducted by TR, HP, ES, JL, MP and NAK. Data generation was done by GWM, SS, SPLT, SD, PMI, JL, MP and NAK. Analysis and reporting was performed by TR, HP, JL, MP and NAK. All authors were involved in manuscript writing and gave approval of the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.