Stephen Hanauer, MD, on the Future of IBD

Dr Stephen Hanauer led off a session on looking in to the future of the diagnosis, management, monitoring and therapies for the treatment of inflammatory bowel disease at the 2023 AIBD conference in Orlando, Florida.

Stephen Hanauer, MD, is the Clifford Joseph Barborka Professor of Medicine at the Feinberg School of Medicine and medical director of the Digestive Health Center at Northwestern University in Chicago, Illinois.

TRANSCRIPT:

Hello. I'm Steve Hanauer from Northwestern University in Chicago, and I'm delighted to be here at Advances in Inflammatory Bowel Disease 2023, our 22nd year. And earlier today, I presented a keynote lecture on the near future of advances in inflammatory bowel disease. In my talk, I included the expanding spectrum of inflammatory bowel disease over the past years that not only includes the traditional Crohn's disease and ulcerative colitis, but also very early onset inflammatory bowel disease and later onsets, including checkpoint inhibitor colitis and other microscopic colidities.

One of the issues we've had all along is understanding the pathogenesis of these diseases. And over the past 40 years or so, we've been exploring both the genetics and the environment, and it's turning out that it's going to be too simple. It's not all one or the other, but it turns out that they both contribute. They're actually synergistic in the development of inflammatory bowel disease at young ages, and these include genetic factors— there are now over 250 genes associated with ulcerative colitis and Crohn's disease—as well as innumerable environmental factors. And, of course, these include the gut microbiome.

Some of these factors include exposure to furry animals at young ages are protective as are vaginal deliveries versus cesarean sections, breastfeeding, and the avoidance of antibiotics in young children are all important protective factors against the development of inflammatory bowel disease. But I think we can consider a 2-hit component. Because some patients have a greater genetic influence, such as families with a lot of IBD, and others exclusively environmental factors.

We've also learned that we have expanded the treatment opportunities now from conventional agents, including aminosalicylates and corticosteroids and traditional immunomodifiers, now to multiple different classes of advanced agents, including TNF blockers, lymphocyte trafficking agents, anticytokine therapies, and our newer sphingosine 1 phosphate modulators as well as JAK inhibitors. But the problem remains that we have a therapeutic ceiling. Only approximately 40 to 50% of our patients are in a remission and less so corticosteroid-free remission. So for the past 30 years or so, we've been combining therapies, such as steroids with immunomodifiers, transitioning from more potent immunomodifiers to less risky therapies over time, but now we need to begin to explore combining different mechanisms of action.

The problem has been, thus far, these have only provided somewhat marginal advantages over any single agent alone. So ultimately, we're going to need to decide what the patient's specific phenotype is. We clearly need better biomarkers to predict who is going to respond to which agent or another. And how are these going to be solved? Well, I think in the near future, they are going to be solved by artificial intelligence. The immense amount of data contributing to genetics, the environment, and specifically the gut microenvironment are incredibly large numbers that are going to take sophisticated computer network programs to really learn in the future. And those programs will then be able to tell us which drug for which individual at each particular point in time. And I think that is the near future of the disease that's going to be rapidly expanded by artificial intelligence, not only from a diagnostic and predictive standpoint, but also from a therapeutic standpoint.