Expert Perspectives on the Optimal Management of Inflammatory Bowel Disease - Episode 3
Important factors to consider when classifying patients’ risk status during the diagnosis of an inflammatory bowel disease and the impact of risk assessment as it relates to treatment selection based on the current therapeutic algorithm.
Stephen Hanauer, MD: We’re discussing the systemic and gut manifestations, and the therapeutic algorithm, or how we position patients, is often based on both the severity of the symptoms at the present time. And Marla, was mentioning, for patients who are uber-sick, that she goes to infliximab because they’ve earned that. But there are obviously different levels, and we have multiple options of therapy. For the most part, our societies have divided patients into those with mild to moderate disease based on their prognosis, not necessarily their symptoms when they present, but their prognosis for progressing onto either more severe ulcerative colitis that might need a colectomy or developing cancer on a long-term basis. And in Crohn disease, there is the risk of the development of transmural complications, such as strictures and fistulas. Societies around the world have divided patients into those with a good prognosis, which in my mind is the minority of patients with Crohn disease, frankly, and those who have a more moderate to severe prognosis. There are several different ways that we can classify those.
Marla mentioned early on that children with more extensive disease, and even early onset disease, have a more severe form of the disease. We know that patients with ileum disease are more likely to have a stricture perhaps than patients with more colonic disease.
And of course, patients who present with these complications, such as a perianal fistula or a hot and heavy extra-intestinal manifestation, are also those. But one of the factors that I find to be most compelling in either ulcerative colitis or Crohn disease, is the presence of deep ulcers at diagnosis. In my mind, those are patients who are automatically at risk for progressive disease. Marla, what do you think?
Marla Dubinsky, MD: Yes, I agree. The depth of the ulceration should help you understand that you need to go to something that has a deeper systemic effect, that’s the way I think about it. That obviously a locally acting anti-inflammatory, even if approved, for example budesonide, is not going to help you with deep ulceration.
Stephen Hanauer, MD: Or mesalamine in ulcerative colitis.
Marla Dubinsky, MD: Yes, or mesalamine, true, in ulcerative colitis. That’s a sign for me that I must step up my game, and I need more effective therapy. I agree with you 100%.
Transcript Edited for Clarity