Edward Barnes, MD, on Positioning Medical Therapy and Surgery for Patients with Ulcerative Colitis

Dr Barnes discusses the factors to consider when determining when and how to position therapeutic options, including surgery, for patients with ulcerative colitis.

Edward Barnes, MD, is an assistant professor at the University of North Carolina at Chapel Hill.

TRANSCRIPT: 

Dr. Edward Barnes:  I'm Ed Barnes, and I am an assistant professor in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill and also in our multidisciplinary center for inflammatory bowel diseases.

It's my pleasure to speak with you today about how we think about positioning surgery in the treatment of patients with ulcerative colitis—in particular, how we think about positioning medical therapy versus surgery and how we make that decision, knowing where we position medical therapy but also some of the complications that can happen after surgery, including pouch-related complications among those patients that have an ileal pouch-anal anastomosis.

I think any of us that treat patients with ulcerative colitis realize there's a growing number of therapies that we have available for the treatment of patients with ulcerative colitis. We've seen a rise in the number of biologics and now small molecule therapies that we have available for the treatment of patients with UC.

With those, I think we've seen a rise in the number of patients who want to try every therapy that's available before they think about having surgery, particularly patients that have the most refractory ulcerative colitis.

What we're also faced with in our clinical decision-making is, is that the right approach? Should we try every therapy that's available, or should we think about doing surgery earlier in the disease process?

I don't think we know the right answer to that question, but some of the things we think about when we see patients with ulcerative colitis — particularly those that have been refractory to multiple different medications— is, what is the likelihood that the next therapy is going to be successful?

We don't necessarily have head-to-head or comparative effectiveness studies that can tell us what the likelihood of a third, a fourth, or even fifth-line therapy is, but that's what we can begin to have a shared decision-making process with the patient to lay out some of those realities as we begin to move through those therapies.

We also need to really balance decision-making about what is the reality that a medical therapy might work versus what the postoperative course might look like, as well.

This is where this also becomes a little bit complicated, although we realize that the likelihood of success in a sequential therapy for ulcerative colitis probably diminishes the more times than a previous therapy has not worked for a patient with UC.

We also realize that although we might bill surgery in some cases as curative for a patient with ulcerative colitis, it probably only cures UC in the sense that we take their colon out. It doesn't cure the fact that they had an underlying inflammatory bowel disease and their risk for inflammatory complications after they have a surgery.

For most patients with refractory ulcerative colitis or UC-related dysplasia, the common surgical approach is going to have a colectomy with an ileal pouch-anal anastomosis. That pouch can be associated with inflammatory complications after surgery.

You can have pouchitis, which happens in about 40% of patients in the first year after surgery and up to 80% of patients over the disease course after that IPPA is created. We also know that about 20% of patients will go on to develop some chronic pouchitis—either chronic antibiotic-dependent pouchitis, where patients take a succession of multiple different antibiotics to keep their symptoms at bay, or chronic antibiotic-refractory pouchitis, where often patients are going back to taking biologic therapies, the same sequential therapies that we were just talking about running through when they had ulcerative colitis.

We also know that patients are at risk to develop Crohn's-like disease to the pouch, with up to 10% of patients developing Crohn's-like disease to the pouch despite of preoperative diagnosis of ulcerative colitis.

What can be tricky about managing a complication like Crohn's-like disease to the pouch is that there's a lot of heterogeneity in both the definitions used to describe the condition itself but also the diagnostic criteria that are used in identifying those patients with that particular inflammatory condition.

We don't have comparative effectiveness studies to know what's the best fourth- or fifth-line therapy to use for ulcerative colitis once patients have failed sequential therapies. We also don't really know at this point what are the best at most efficacious or most effective therapies to use in these chronic and inflammatory conditions of the pouch.

I hope what I'm relaying here is that we have a lot of work to do to understand how to better treat these inflammatory conditions, both in the preoperative setting for the very simple ulcerative colitis patient, but also in the postoperative setting for those unfortunate patients that develop inflammatory complications.

In all of this to tie together, it really makes balancing this decision-making process for the ulcerative colitis patient that's having significant complications after the failure of multiple therapies difficult.

My advice to you would be to really think through with your individual patient. What are their goals? How are you best going to try and improve their quality of life? What do you think the success of that next therapy is going to be?

A lot of this is going to be based in part on what their prior therapy regimen has been and what other things are going on in their life. It may be quality of life things. It may be extra-intestinal manifestations, but this has to be a really individualized decision-making process.

If you can individualize that decision until we have better comparative effectiveness data, this can start to build a decision algorithm, both on the preoperative side and the postoperative side, for that patient that does develop complications, particularly those complications of the pouch.

I thank you very much for your time. I hope that this was an important or at least an informative discussion to start to think about how to discuss this with your patients.