David T. Rubin, MD, on Proactive Care in IBD Management

A proactive approach and treat to target strategies are needed for the management of inflammatory bowel disease (IBD), according to a presentation by David T. Rubin, MD, at the 2019 IAS Meeting.

Rubin, who is chief of the section of Gastroenterology, Hepatology, and Nutrition at the University of Chicago, said the current goals of IBD management are to clarify disease type and severity, induce remission rapidly—defined by patient-reported outcomes and an objective marker—, maintain steroid-free remission, and to change the natural history of IBD, which means to avoid hospitalization and surgery, avoid drug-related and disease-related complications, and reduce costs of care.

However, challenges in IBD management persist. These include:

• heterogeneity;
• large primary nonresponse;
• large secondary loss of response;
• disease changes over time; and
• the patient changes over time.

“One of the most pressing unmet needs in IBD, and perhaps all inflammatory disorders, is sequencing and choice of therapy,” Rubin said during his presentation. “Biomarkers are still missing…until we make some definitive process in translational and basic science, we will continue to struggle.”

Another challenge is the traditional treatment strategy for IBD is becoming outdated but is still used by payers and still taught, according to Rubin. “The inherent approach is used; patients have to get sicker to get to the next level,” he said. “We are always trying to catch up and we are not doing this in a proactive way.”

Strategies to overcome challenges in IBD management include optimizing treatment, embracing surgery, use therapeutic drug monitoring for high-risk patients, and choosing therapeutics and sequencing wisely.

Future goals for IBD management are to individualize care, achieve deep remission, optimize therapy, and use proactive management.

Treat to target strategies are also needed for more high-risk patients in order to choose the right therapy and time specific follow-up to optimize treatment.

 “We know real world treat to target is possible with minimal adjustments of our existing therapies,” Rubin said.

Rubin highlighted a study by Colombel et al that showed patients driven by a treat to target strategy for their Crohn disease (CD) were more likely to reach mucosal healing compared with individuals who received clinical management for CD.

Keys to implanting a treat to target approach for IBD management include having a willing patient, an informed provider, reliable disease activity measure, available treatment options, and monitoring strategies for after the target(s) is reached.

A collaborative effort is also important for IBD management.

“We need to work with all of our colleagues to take care of these complex patients,” Rubin said.

Reference:

Rubin DT. Targeting IBD: hitting the mark in today’s treatment landscape. Presented at: Interdisciplinary Autoimmune Summit; April 5-7, 2019; Chicago, IL.