Bincy Abraham, MD, on IBD Treatment Goals and Strategies

Elimination of symptoms alone is no longer the goal; mucosal healing, endoscopic remission, and an improved quality of life are the ultimate goals for patients with inflammatory bowel disease (IBD), Bincy Abraham, MD stressed during her presentation at the Advances in Inflammatory Bowel Disease Regionals virtual regional meeting, August 27.

Dr Abraham is a professor of clinical medicine at Houston Methodist Academic Institute, a professor and director of the Fondren IBD Program and the director of the Gastroenterology and Hepatology Fellowship.

“The goals of therapy in IBD have changed over the years”, Dr Abraham noted. Clinical remission was, and still is, the initial goal. “But that’s not enough,” she insisted. “Besides eliminating all symptoms, we need to get our patients to endoscopic remission and histological healing. This would reduce the overall need for hospitalizations and surgeries and ultimately cause a delay in clinical relapses among patients with IBD,” she said. Additionally, through histological healing, the number of concurrent dysplasia and colon cancer incidences among patients with ulcerative colitis (UC) and Crohn disease (CD) would decline, too.

In managing patients with IBD, Dr Abraham focused on the STRIDE II guidelines for establishing therapeutic goals for treat-to-target strategies. She targets the treatment of patients with active IBD according to their specific symptoms and risks to achieve symptomatic remission and normalization of C-reactive protein (CRP). “By achieving this deeper remission, we can get to a better quality of life standards for the patients and the absence of disability over time,” she explained. Clinicians are encouraged to pause and reassess the risks and adjust the dosing and the patients’ reaction to treatment until the long-term targets are met.

Dr Abraham’s goals are in line with the 2-fold goals laid out by the American College of Gastroenterology (ACG) guidelines – to achieve mucosal healing and aim for a better quality of life. For mucosal healing, providers can track endoscopic scores to monitor patient response and use fecal biomarkers such as fecal calprotectin and lactoferrin for noninvasive monitoring. Paying attention to the patient’s psychoemotional response is of utmost importance, too. Effectively managing their stress levels, anxiety, and depression would lead to an over better quality of life.

According to the AGA guidelines, it is important to assess inflammatory status in each individual through clinical lab tests, imaging modalities, endoscopies, or computed tomography enterography in order to determine any comorbidities or therapy or disease-related complications.

Selecting therapies based on disease severity helps in deciding the appropriate course of action. “Patients with mild disease intensity may be managed with aminosalicylate or budesonide, whereas on the other hand, for patients with more severe disease, you may want to start with biologic therapy or small molecule therapy,” she said.

Predicting severe disease in CD or UC could help to determine early intensive therapy and the initial use of corticosteroids. Predictors of severity among patients with CD include early age of onset, current smoking habits, fistulizing disease, perianal lesions at diagnosis, and the need for corticosteroids at the first emergence of flare. To determine the severity of disease among patients with UC, factors such as early need for corticosteroids or hospitalization, rate of active infection, and the extent and duration of the disease should be considered.

Dr Abraham recommends Mayo endoscopic scale to determine disease severity for UC and Simple Endoscopic Score for CD. Regardless of the system, the aim is to get a score of 0.

Speaking about asymptomatic disease progression, she advises practitioners not to depend on symptoms alone. “Symptoms often do not correlate with inflammation,” she stated. Dr Abraham cited several studies that showed that asymptomatic patients may have active disease. The CALM study, for example, revealed that the patient cohort whose disease severity was assessed by biomarkers and symptoms severity achieved a significantly higher rate of endoscopic remission at week 48 (46%) in comparison to the cohort for which clinical symptoms alone were used to determine disease severity and progression (30%).

The STARDUST trial of ustekinumab among patients with CD, the researchers found higher numerical values of endoscopic response in treat-to-target vs standard of care (37.7% vs 29.9% at week 48). “However, the statistical difference between the 2 strategies was not as significant as the results obtained from the CALM study,” she noted.

A 2007 multicenter study shed light on mucosal healing as an important prognostic marker of long-term disease. The study showed that mucosal healing after 1 year of treatment could lead to reduced subsequent disease activity as well as decreased need for follow-up treatments. While Dr Abraham agreed that mucosal healing could be a good clinical indicator and treatment goals in IBD, it shouldn’t be the only determinant of patient health, she stressed. “Patients would not like to be poked every time for assessing their progress. Using other markers such as CRP, fecal calprotectin, fecal lactoferrin, imaging, or intestinal ultrasound would be noninvasive and well-accepted, too, especially when endoscopy is not ideal,” she stated.

Among patients whose IUS showed no evidence of disease activity, 84.3% chose to remain on their current therapy, while more than half (55.2%) who did show continued disease activity opted to continue with their treatment regimens; 42.9% of patients with IUS findings of disease activity preferred to change therapies. Dr Abraham said this finding indicates that IUS could be a useful tool for monitoring and positioning therapies among patients with IBD.

Dr Abraham stressed on the importance of assessing disease severity to initiate appropriate therapies and set up follow-up targets as well. For long-term improvement in outcomes, the goal is to move from symptomatic remission to endoscopic remission and utilize noninvasive markers when colonoscopy is not ideal.

“Start therapy early,” she asserted. “Especially for patients with CD, it may be important to take advantage of the window of opportunity before they progress into more complications which require surgeries. This is also true for patients with UC to proactively assess their severity levels and start therapy to avoid huge future costs and complications. All in all, continue monitoring to maintain remission long-term, ideally for the rest of their lives.”

—Priyam Vora

Reference:
Abraham B. Treatment goals and strategies. Presented at: Advances in Inflammatory Bowel Disease Regionals Virtual; August 27, 2022.