GASTROENTEROLOGY & GI SURGERY

Crohn's Disease and Ulcerative Colitis: It's Complicated

Oct. 15, 2021 - Eden McCleskey

Medical care for patients with inflammatory bowel disease (IBD) comprises a wide range of pharmacological, nutritional, endoscopic and surgical therapies. For an umbrella term that basically only covers two conditions, Crohn's disease and ulcerative colitis, there's a surprising number of variations and factors affecting treatment paths.

If you want to see some busy slides, look up the principles of management for acute severe ulcerative colitis or ileocecal Crohn's disease. It's likely to be a case of TLDR before you get past "Establishing the Diagnosis, Extent, Site and Severity." Or check out an IBD treatment flowchart, just beware you might need a compass and pickaxe to get through.

For Dr. Bincy Abraham, an IBD specialist at Houston Methodist, understanding and managing these complexities comes with the territory. She's made it her mission to not only provide the best care for patients who need the highest level of IBD expertise but to help non-IBD specialists provide the quality of care the disease demands.

To that end, Dr. Abraham will talk about "Starting Therapy in IBD" at the American College of Gastroenterology 2021 conference on Oct. 25, part of a three-speaker series aimed at keeping GI providers up to date on the latest evidence-based guidelines for IBD. She sat down with Leading Medicine to discuss the key points she hopes the audience will take away from her talk.

Q: What makes inflammatory bowel disease complex?

Recognizing symptoms and going to the doctor to get diagnosed is the first hurdle. Onset of both Crohn's disease and ulcerative colitis can occur anywhere from childhood to retirement age, which is a wide range. Also, people are very familiar with GI symptoms. They've probably experienced them many times throughout their lives without it being a big deal, and it takes a while to recognize that this time it's a big deal and it's not going away.

So, from the beginning, there's already a wide range of severity, there's how long they've been living with it and there's possible damage that has occurred. There are also different locations in the GI tract that could potentially be affected. All of these can affect the efficacy and options for treatment.

There are many different medications with different benefits and side effects, and it's relatively difficult to predict how each patient will respond. Maybe they'll respond to the treatment but have a lot of side effects. Maybe they won't have side effects but they also won't have much of a response. Maybe the treatment will work well for a while but then stop working.

These are immune-mediated diseases so everyone's immune system is doing its own thing. That means there's more trial and error involved, and close monitoring is needed when you start any new treatment. There's also a certain number of contraindications to be aware of in selecting therapy and a certain amount of misdiagnosing and other conditions that mimic these disorders, and if you don't really take your time to evaluate these, you could be overtreating or undertreating the patient. But at the same time, if you take too much time to choose and start treatment, you could be missing a critical window of opportunity to prevent escalation of disease activity and structural damage.

Q: Sounds very high stakes, and intimidating. Is it?

I mean, yes and no. In medicine, the stakes can always be high. Certainly, in this population of patients that is true as well. But the truth is, most of these patients have mild to moderate IBD, and most do go on to reach our target of clinical and endoscopic remission. They have the disease, but they either have no symptoms or very manageable ones, and they live a normal quality of life with it.

One of the most important points I like to stress is to utilize the 'treat to target' approach. Let's say you do your best to figure out the best initial treatment for the patient, but they do not respond. You have not done anything wrong, as we cannot predict yet who will respond to each therapy. As long as you are monitoring your patient appropriately and following the treat-to-target path — initially to achieve remission of symptoms, then to target deep healing — you simply reassess them and adjust their therapy until you reach that target.

Sometimes it's a matter of getting more dosing or increasing the frequency of the medication or stepping up therapy to small molecules or biologics if they are not already on them. Then you monitor the response to the changes you have made, and if that still doesn't work, keep making adjustments or consider referring to a specialist. That's what specialists like me are here for. But the key is to keep monitoring or adjusting treatment until you're on the right path to getting your patients to healing.

It can seem very complex. I mean, I literally just told you it was complex. But as long as we are working towards that target, then we're doing the best for the patient. Chances are very good that eventually they will get there.

Q: What are some other important points you want to make at the conference?

I like to stress this 'window of opportunity.' Yes, we have to personalize the treatment, depending on severity and other illnesses they've had, and there are labs we need to do before we start any treatment. But starting as early as possible is very important so that we can get rid of the inflammation before irreversible structural damage occurs. Because that's what complicates things for the patients long-term. Time is of the essence at the beginning. That's a point I like to make very clearly.

And going along with that — we have so many options. Which medication do we use first? I don't necessarily know the answer to that, but there are categories. You don't want to start someone with mild inflammation on very high-level medications. You're going to overtreat them. And you don't want to start someone with severe inflammation on a mild treatment. That's giving them more time for the inflammation to continue to get worse. So stratifying the medications based on the disease severity is an important part of personalizing care.

Q: Are there changes that people need to be aware of? New forms of treatment?

There is a ton of research going on right now in immune therapies, implantable medication delivery, fecal transplants, stem cells, etc. But those things take a lot of time to develop.

We will be seeing more medications approved for Crohn's disease and ulcerative colitis in the upcoming years. The most recent ones are biologics and small molecules. Some block specific "cytokines" or its effects in the immune pathway that cause inflammation, and others prevent immune cells from getting to the gut. Based on the clinical studies, they show much better efficacy compared to the milder agents and are more targeted towards specific causes of inflammation rather than an overall immunosuppressive medication. That's why, for moderate to severe disease, we want to start with those.

I also spend some time going over testing, labs and the assessment of patients that the clinicians will need to know about these newer medications so they're comfortable using them. It's very exciting to have more therapy options to turn to in those cases where the patient does not respond to standard therapy. Going back to what I said earlier, the important thing is to keep trying until you get your patients to where they need to be.