Jessica Allegretti, MD: Optimizing Existing Therapies for IBD

Dr Allegretti reviews her presentation from the AIBD regional meetings on how to most effectively use existing therapies and apply a treat-to-target approach in managing inflammatory bowel disease.

Jessica Allegretti, MD, is an associate professor at Harvard Medical School and medical director of the Crohn's & Colitis Center and director of the fecal microbiota transplant program at Brigham and Women's Hospital in Boston, Massachusetts.

TRANSCRIPT:

Hi, everyone. My name is Jessica Allegretti, and I'm the medical director of the Crohn's and Colitis Center at the Brigham and Women's Hospital in Boston. I am one of the faculty speakers at the AIBD Regional Conference. Today, I'm going to be discussing with you my talk, Optimizing Existing Therapies In Patients With Inflammatory Bowel Disease. Really, what we're going to be discussing is goals of IBD management. Essentially, you want to make the diagnosis as quickly as possible. You want to induce remission rapidly and maintain steroid-free remission, achieve normal bowel function, and overall, improve our patient's quality of life. That's the goal of everything we're doing. But, of course, there are several challenges with this as prior strategies tended to be symptom-based or complication-based and not really focused on treating to specific targets.

So if we think about the paradigm shift that has happened in the management of IBD, we used to think about just really improving symptoms with a goal of overall response. Now we know deep remission is the goal with really a much deeper level of mucosal healing, and ultimately, again, preventing bowel damage and disability for our patients. We know that there are several prognostic factors that will predict who's going to have a complicated disease course are not in IBD. So it's important to identify those in both Crohn's and ulcerative colitis. Those can be things like extensive anatomical involvement, diagnosis at younger age, need for steroids, multiple hospitalizations, or having a surgery already. So what I'm focusing on is really the 3 main pillars, which include early intervention, treating to target, and then tight control.

So with regards to the first pillar, which is early intervention, we know that there is a window of opportunity. If you can diagnose a patient early before irreversible bowel damage has occurred, you are going to alter that patient's disease and their life. You're going to prevent or at least delay surgery and ultimately, improve their quality of life. We know that the best way to do this is by using advanced therapies early. There's a lot of data on anti-TNF use and especially combination therapy in both ulcerative colitis and Crohn's disease. That being said, the use of combination therapy is not a one-size-fits-all model, and you do need to take into account those who may have risk factors or other comorbidities and where combination therapy may not be appropriate. We're also going to be discussing STRIDE and the STRIDE guidance, which helps us understand treating to target. There are several targets for both Crohn's and ulcerative colitis, such as patient-reported outcomes, biomarkers like CRP and fecal calprotectin, imaging, and of course, colonoscopy, which is still the gold standard, looking at, again, endoscopic and mucosal outcomes.

Really, what the goal of all of this is that you want to identify a patient who has those high risk factors. You want to get them on an advanced therapy early, and then you want to set targets that make sense for that patient. Then you want to be following up with them really closely. If you're at any point, not hitting those targets, you want to be circling back and trying to ask yourself why. Is it because the patient's not on the right medication? Are they underdosed or is there something else going on? You want to be able to be nimble and make changes in real time so that the patient gets well as quickly as possible.

So to summarize my talk, again, the main goal is really to change the disease course and improve the quality of life of our patients with IBD. We want to understand how to identify those with the severe disease and are more likely to have a more severe or problematic disease course. We want to understand that important management strategies include early intervention, treating to target, and ultimately achieving type control. We know that biologics and small molecules are what we now call advanced therapies are effective and should be used early in those high-risk patients. Again, early biologic use with or without an immunomodulator in patients with moderate to severe disease should be used at those with high risk for disability, and again, that combination therapy is not one-size-fits-all. So you need to decide if the combination with an immunomodulator is appropriate for the patient you have sitting in front of you and treat beyond symptoms. We are not treating to symptoms alone, use your clinical judgment. So thank you all for your time and attention, and I hope you enjoy the meeting.