Optimal Management of Biologics in Crohn’s Disease - Episode 4
Dr Bincy P. Abraham leads a discussion on factors to consider when selecting a therapy for the management of Crohn’s disease.
David P. Hudesman, MD: Dr. Abraham, when we're talking about our different options, before we get into the actual therapies, what factors are important on picking a therapy for a patient? So when you're having these discussions -
Bincy P. Abraham, MD, MS, AGAF, FACG: Yes, I guess -
David P. Hudesman, MD: What factors are you thinking about?
Bincy P. Abraham, MD, MS, AGAF, FACG: With lots of medications now coming out to market available for us, it seems like it makes it very difficult to choose which one is correct. We don't have precision medicine yet for our patients with Crohn's disease. This is how I go about it. First and foremost, we got to look at the severity of the disease, location of the disease, and choose appropriately. For example, you have someone who has, let's say, mild ileal disease, a few aphthous ulcers, but we know there's a family history of Crohn's and biopsies confirms that this is Crohn's disease, I'm not going to put them on top gun therapies right away. I'm going to start with, let's say, a local acting steroid, such as budesonide. And see how they improve. And if they respond, great, fantastic. We don't need to step up therapy at that point. On the other hand, if I have a patient who comes in with severe pancolonic inflammation and ileal inflammation and it was a struggle to get in to the ileocecal valve because inflammation was so severe, then I'm going to go top gun and choose the most efficacious therapy for that patient because I want to prevent progression, I want to prevent them from getting that colon out or having a resection of their small bowel or end up getting a stricture or fistula in the future. I will choose according to the severity, that's number one. Then, the other thing considered is comorbidities of the patient, do they have concomitant rheumatoid arthritis? Or do they have another disease, such as multiple sclerosis? If that's the case, then I will consider a medication that might cover both if they're not already on that appropriate therapy to see if we can consolidate treatment that may be FDA approved for both diseases. We're not putting them on multiple agents at the same time where we can have one mechanism of action that treats concomitant diseases. On the other hand, I also look to make sure that they don't have any comorbidities that could be a potential risk of putting them on a specific therapy. For example, having older patient who has significant congestive heart failure. I want to avoid the entire class of anti TNF's because we know that it can make congestive heart failure worse. That's another component of it. And then, the third component, it would be the patient's preference. If, let's say, the patient states that, "I don't have time to come in to get infusions done. I'm really busy." Then I don't want to say that you must put this patient on an infusion where they're not going to come in for it and choose a, hopefully, similar efficacious medication that could be a subcutaneous agent, or hopefully, in the future, an oral agent. On the other hand, if I have a patient that's deadly afraid of needles and would not want to take any injection at home, then we need to consider different therapy where they're comfortable or a nurse is able to give infusion to that patient. Consider the patient's preferences as well. And the last, of course, which may be the most important will be insurance coverage. I won't go into that here, because that can vary based on region and what they have and what they change to at their next, job et cetera.
David P. Hudesman, MD: Any other thoughts on this?
Jennifer Seminerio, MD: What Dr Abraham is touching on is the fact that it is just such an individualized approach. Every situation, you could have an entire treatment plan in your head, and it could get completely squashed when you walk into the room. It just sort of is this concept that we've talked about these entire conversations thus far. Shared decision making is about being able to give our patients the options, being able to guide them in a direction based on the confounders of the disease based on where they're at in terms of severity. But then also understanding that you may have to go through something that doesn't follow the guidelines because of where your patient is at that time.
Miguel Regueiro, MD, AGAF, FACG, FACP: Yes, so the only thing I'll add is that this is a journey and so when we start a patient newly on a therapy or we switch a patient on a therapy, I like to break down the next year into segments. If you talk to a patient, especially newly diagnosed about a 10 year plan that will be overwhelming and honestly it can be somewhat depressing. The patient is thinking, I'm newly diagnosed. I'm worried. I don't understand this. Am I going to have an ostomy or get cancer at some point? So, I usually give a snapshot of a year and I break it down and I say, Whatever the therapy is that we start, and we'll talk advanced therapy, I want to know in two months that you're feeling better. We all said symptoms first. I think everybody agrees. But then quickly use the biomarkers and Dr. Asfali mentioned CRP, fecal calprotectin. So, that's the first two months. And in the first 6 months, I used to do scopes at 6 months now I'm actually backing off in Crohn's. And if their fecal calprotectin is improving, if your intestinal ultrasound and that looks better, then at six months we say you're doing well and then I'll do a colonoscopy at a year or a cross sectional imaging. The reason I do that is that I think we do also see a bit of a lag in improvement, and we burn through our biologics and advanced therapies too quickly. That's the snapshots of the first year. But I think as Anita said, and I agree, it's also what do you want, the patient want, what's your expectation? But sometimes breaking into those small steps over a year, whether they've been on therapy, or this is new to them, it's easier to comprehend and meet those goals.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: And I like to add, words matter. Early appropriate therapy for an aggressive disease phenotype. And what is that aggressive disease phenotype? As you mentioned, we're looking at prognostic factors that we know that if we do not initiate appropriate therapy for that individual the risk for disease progression continues. We only have a small therapeutic window maybe perhaps just a few years, if that, to initiate appropriate therapy for each individual patient.
David P. Hudesman, MD: Yes, I agree completely, and as what was said is, for this patient, I always start with efficacy as you already do. If it's not going to work, all these other factors are moot. Once your past efficacy you're talking about their patient lifestyle, safety, onset of action. And then you put that all together with a patient to make your option.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: Correct.
Transcript Edited for Clarity