Novel Expert Perspectives in Treating Moderate-to-Severe Ulcerative Colitis - Episode 13
David P. Hudesman, MD; Marla Dubinsky, MD; Ellen J. Scherl, MD; and Miguel Regueiro, MD, provide advice for physicians treating patients with ulcerative colitis.
Miguel Regueiro, MD: Dave, we talked a lot about unmet needs, but what advice you share with physicians taking care of ulcerative colitis [UC]?
David P. Hudesman, MD: Treat early. But when you’re treating early, it’s important to monitor your patient. Not just symptoms alone but with biomarkers, fecal calprotectin, CRP [C-reactive protein], and then repeating a colonoscopy. With that, the enemy of good is perfect. What we’re seeing now, as we’ve been talking about, is a lot of referrals where patients are cycling through therapies where the colon looked bad. From when it started to 6 months later, it looks significantly better, over 50% better, but they’re not healed. It’s not perfect. Then we switch to the next therapy. We had a nice discussion showing that we want to push that ceiling, but we’re not there.
When we’re looking at the trials, maybe half our patients hit endoscopic remission. We can do better, but that’s about right. If a patient is getting and feeling better, if their biomarkers are improving, if the colonoscopy is looking better, that’s a good thing. Maybe we optimize what we’re on, but we shouldn’t just reflexively switch because we could do a lot of harm in the short term. They might not respond to that mechanism or down the road they could lose response. Some patients respond quickly, and others take 6 months, a year, or longer to fully heal if we could get there. Be patient and monitor the patient.
Miguel Regueiro, MD: “Don’t let perfect be the enemy of good”—I like the way you said that. We must get it right in induction, but we may be OK, given a little time. It’s not opposite messages necessarily; it’s a continuum. To your point, at 6 or 9 months, if you do another colonoscopy and the patient was at Mayo [endoscopic score] 3 and now they’re at Mayo 1 and looking much better, then I don’t think that’s a time to panic and switch to another therapy. We can optimize within that group if there’s the ability to, but we also don’t want to have a patient stuck on steroids for 6 months with a Mayo 2/3 and saying they’re feeling better, but they have a lot of steroid adverse effects. It’s always that fine balance. Marla, what advice do you give physicians treating ulcerative colitis?
Marla Dubinsky, MD: It goes back to what we’ve been saying: first we need to understand the patient’s goals. We start with that. We must understand that our drugs work for symptoms. Most people respond. That’s less of our problem. It’s more the durability and sustainability, and lots of things go into that. We have the ability to say that every drug has its place in the journey. This is a long road. As Dan Present used to say, this isn’t a sprint; it’s a marathon. We can treatments to goal-orient it for the patient, but we must be able to have the right discussion: it’s to keep you out of the OR [operating room], from having a disability or progressive bowel wall damage and the repercussions from that. If we could use the right therapy to heal your lining, you’ll have not only symptomatic improvement but a durable response. You’ll be able to do everything you want to do despite this disease. That’s what we need to get better at.
We get so caught up in trying to push our narrative without making it the narrative the patient needs and wants to hear. How do we meet in the middle? That’s the biggest challenge we face. Ellen discussed that in UC, steroids and 5-ASAs [5-aminosalicylic acids] are it. Even in Crohn disease, that’s what…research showed us. There was a huge gap where there was no exit strategy, so people are free-floating in this gap, asking what’s next. We must have that discussion early to let them know we need an exit strategy.
Miguel Regueiro, MD: Ellen, what advice are you giving your physicians treating UC?
Ellen J. Scherl, MD: We can’t underscore enough the importance of an exit strategy when you start steroids. We should look to the rheumatologist, 7 weeks in the best trial. Let’s shorten that when the patient needs another therapy. It’s fascinating—patient engagement. Algorithm medicine works for maybe 80% to 90%, but even the ones who fit into the algorithms don’t want to be there. For the discussion of diet and nutrition, patients often start to have increased fiber because they’re sick, so they’re going to change to a higher-fiber diet. That’s something that we can meet with our colleagues about because that’s simple. Where are the patients? What did they think about the microbiome? How much Coke, how much carbohydrates, sugars, etc? That way, we get a chance to know where the patient is. You don’t want to push our narrative. We must listen to the patient. Where are they? Are they taking NSAIDs [nonsteroidal anti-inflammatory drugs] for their extraintestinal manifestations and driving the disease? In our increasingly pressured world, we must find a time to listen to the patient and understand where they are in terms of complementary medicine while we’re developing what we think is the right approach, the right strategy, for mucosal healing and decreased progression. This is a dialogue with our patients and colleagues who are in the real world.
Miguel Regueiro, MD: The advice, thinking about our trainees or those coming out of fellowship, is exactly what you said. We’ve been saying it goes back to the basics, listen to the patient. It’s amazing that in first 5 minutes of a conversation, you can learn so much that guides your decisions on therapy.
Transcript Edited for Clarity