Sara Horst, MD, on Risk Stratification and Disease Monitoring for Patients With IBD

Dr Horst reviews her presentation from the Advances in Inflammatory Bowel Diseases regional meeting about how risk stratification and disease monitoring can improve outcomes among patients with IBD.

Sara Horst, MD, is a gastroenterologist with the Vanderbilt University Medical Center IBD Clinic in Nashville, Tennessee.

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TRANSCRIPT:

Sarah Horst:

Hi, I'm Sarah Horst, a gastroenterologist at Vanderbilt University Medical Center who specializes in the care of inflammatory bowel disease. And I was really excited to talk about the topic of risk stratification and disease monitoring in patients with inflammatory bowel disease at the recent AIBD Regional course. I'll just summarize a little bit of what I talked about.

So I think it's really important to think about risk stratification for our patients with inflammatory bowel disease because it can help us understand what sort of medicines they should be on, how early we need to start treating, and things that we need to think about for the patient in the future. For example, when you think about patients with inflammatory bowel disease like ulcerative colitis, there are some actual prognostic factors when you think about the patient and their risk for something like colectomy that are pretty well thought out and well delineated in the literature now, and it's something we really need to think about, we need to think about the whole patient, not just their current symptoms.

So for example, for an ulcerative colitis patient, if their age is less than 40, they have extensive colitis, they have severe endoscopic disease, they've been hospitalized, or they have elevated CRP or low serum albumin, this person really is at higher risk for colectomy. And so we really need to think about probably early biologic therapy in someone like this.

When you think about someone who has Crohn's disease, we know that the likelihood that a patient with Crohn's disease is not going to have some sort of complications such as penetrating disease or stricturing disease, is actually pretty low. And so we really need to think about risk factors that increase that: smoking, male gender, penetrating disease, early steroid use, small bowel disease extent only. These are really risk factors that again, really portend to worsening outcomes for the patient and we need to think about early treatment for them.

And then when we think about targets when we start treatment, what are those? What does that actually entail in this current landscape for patients with IBD? We can think about current targets, like symptom control, lab values, endoscopy or radiology. And why should we do this? Well, we know there is actually some data showing that if we treat to target, if we treat to optimize these more than just symptom-based ways to look at inflammatory bowel disease, we know that we can improve outcomes. For example, the CALM study showed that if we looked at biomarkers for evaluating mucosal healing, that we could really improve long-term mucosal healing if we're using these sorts of tight monitoring options.

I think the other thing I really focused on in the talk was when you think about monitoring, if you're going to be monitoring with fecal calprotectin or CRP or however you do it, you need to do it systematically, use the patient as their own control. Do it frequently, often, and if you're thinking about endoscopy, really think about using scoring systems. It's going to help you if a patient moves to a new provider, you're going to have more of a streamlined way to evaluate. So if you think about for ulcerative colitis using either the Mayo score or other scoring strategies such as the ulcerative colitis endoscopic index of severity, that's great. And also looking at Crohn's disease, thinking about if you can sort of up your game and look at a simple endoscopic scoring system for Crohn's disease. So I advocated for that.

And I think the bottom line is when we're thinking about targets, it's really figure out your strategy, make sure you do it frequently and often for the patient. Right now, our treatment goals really in endoscopy are we're trying to get towards endoscopic response or remission. I don't think we have enough data to say histologic healing is the way to go yet, but we know that silent inflammation can lead to worse outcomes. We really need to think about tight control for our patients with inflammatory bowel disease. Thank you.

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