Optimal Management of Biologics in Crohn’s Disease - Episode 3
Experts in gastroenterology review goals of therapy for the management of Crohn’s disease, utilizing a treat-to-target approach for treatment, and the importance of shared decision-making.
David P. Hudesman, MD: Following up on that, Dr Regueiro, we have a patient now diagnosed with Chron's disease. Before we get into the therapies, what do you discuss with them on the end goals of treatment or the goals of therapies?
Miguel Regueiro, MD, AGAF, FACG, FACP: You've heard some of the diagnostic tools. And it's setting expectation in goals. First of all, there needs to be some shared decision discussion. We often will ask what the patient wants, one, out of the visit, but, two, out of the goals of their therapy. And understanding the day in and day out of what they're doing, is so key. Whether it be work, school, whatever it may be they're doing in life. And then, beyond that when we set goals, we want them to feel better. We want the symptom improvement, and we'd like that over relatively short period of time. Ideally, within 2 months. Sooner even better. But then, everybody mentioned some of the tools we're using, we're now this treat-to-target approach where goals are not only making the patient feel better, which is obviously first and foremost. But then, also healing the bowel. And healing the bowel can be measuring some of the biomarkers, intestinal ultrasound, cross sectional imaging, endoscopy. We want them to get as nearly back to normal as possible. Now, it may not always be possible to get completely normal, but it's close to what looked to be normal as possible. The days of treating patients just the symptoms and realizing that their disease progresses and that they end up having surgery are really gone. We're making quicker decisions earlier, symptom, and objectively.
David P. Hudesman, MD: Great. And Dr Afzali, maybe you could further elaborate on treat-to-target?
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: Yes.
David P. Hudesman, MD: How do you use that practically in the clinical practice?
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: It's exactly as Dr Regueiro mentioned, as we know that symptoms don't correlate with the disease. That the mucousal healing endoscopic improvement, histologic healing, those are the targets that are associated with ultimately impacting the natural progression of the disease, it's those targets that we know reduces risks for hospitalizations, steroids, surgery, et cetera. And when we talk about this treat-to-target strategies, recognizing and, of course, no patient will be on any therapy if it doesn't make them feel better. Symptoms are important. But aside from symptoms, we also want to ensure that we're aiming for some of these additional targets, because we're trying to reduce the progression of a potentially disabling disease course. And that's where we want to have improvement in the biomarkers, another intermediate target, if you will. And that's also where the endoscopic improvement and healing and histology comes into play as well.
David P. Hudesman, MD: And Dr Regueiro, how do you use treatment guidelines, right? Some of our guidelines from our national organization in your practice and balance that with your real world practice and real world evidence?
Miguel Regueiro, MD, AGAF, FACG, FACP: I guess the honest answer is in my real-world practice.
David P. Hudesman, MD: Right.
Miguel Regueiro, MD, AGAF, FACG, FACP: I'm not necessarily following the guidelines specifically. However, the guidelines have brought us so far away in terms of understanding this treat-to-target approach. And what that means, for about 80% of Crohn's patients were starting an advanced therapy earlier. I think the guidelines, I'd love to say, this is 100%, but the guidelines also might help from a payer perspective in terms of when we look at treatments. However, we still have a long way to go, and we all know that on this panel. And then, the guidelines, for me, it's more probably internal to all of our practices when we talk to patients as far as our treatment expectation goals and what therapies are available. Starting to have that shared decision approach, so not steroids repeatedly, not in an effective therapy repeatedly. And I think the guidelines have done a nice job of spelling that out.
David P. Hudesman, MD: Right. And just to emphasize for treat-to-target, right, it's more than symptoms, but symptoms are still very important. Sometimes, that gets lost a little bit. And another important part we ultimately want our patients to be healed endoscopically and histologically. But that's not always obtainable. As we were talking about earlier, where everybody has their own Crohn's disease, I think everybody's target's a little bit different.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: Absolutely.
David P. Hudesman, MD: Having that upfront discussions are extremely important.
Miguel Regueiro, MD, AGAF, FACG, FACP: To your point about that, the STRIDE-II guidelines, if you look at those symptoms at the very first.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: Absolutely.
Miguel Regueiro, MD, AGAF, FACG, FACP: And then, it's objective healing.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: I appreciate also how you want to identify what are the goals for the patient as well. Because this is what and how we could optimize treatment adherence and make sure through shared decision making that we're understanding what are their goals. We're talking about histology and endoscopic healing, XYZ, perhaps our patient just wants to sit through entire class and not have to rush to the restroom.
Bincy P. Abraham, MD, MS, AGAF, FACG: Right.
David P. Hudesman, MD: Exactly. Why don't we build on that, Dr Seminerio? Talk a little bit more about shared decision making and how that looks.
Jennifer Seminerio, MD: And to the point of what my colleagues are saying, when we looked at those STRIDE-II guidelines, and you ask patients what's the most important factor to them, it is clinical symptoms. As we have these conversations, it's exceedingly important for us as healthier providers to not put their needs aside, but to figure out a way to make their needs important while also incorporating what our goals are in the long term. And shared decision making is the process of taking into consideration what's very important and explaining why there's more to it than that. As we talk about why we've moved away from just symptom management, it's because we have multiple studies that have shown that symptoms don't always match disease severity. There's data that has been correlated with the fact that getting symptoms under controlled as your only target is going to lead to poor outcomes in the long term. I think that when you can sit down and explain that to the patients, make it relatable to them, explain why you're making the suggestions that you're suggesting. And then, what I always say to them, is that at the end of the day, our approach is going to be a team, because it's their choice and it's their body. And if we come in there and we tell them, it's our way or no way, ultimately, we're going to lose our patients and we're going to lose an opportunity. And what's so great is a lesson I learned from somebody sitting on this panel, Dr Regueiro, is I'd rather keep them coming in to my office and keep the discussion flowing than lose them by trying to pressure them into something that they're not ready for.
David P. Hudesman, MD: That's a great point. That's something we always see. Yes, we have our very acutely ill patients, and that discussion's a little bit different. But realistically, it might take those, at that extra visit, a few months to go back doctor-patient relationship to get them there. Any other thoughts?
Bincy P. Abraham, MD, MS, AGAF, FACG: Speaking about those goals, it's also important that we talk about short term goals versus long term goals. At short term goal, we're not worried about histological healing or remission at the time, we want our patients to get better symptomatically improved so that they can sit through a class or go out to eat without the worry of having to rush to the bathroom or have abdominal pain immediately afterwards. If we can get them there, that's great. But we may not have achieved endoscopic healing at the time, but that's OK. So, then, we move forward hoping with more time with whichever medication that you choose or even optimizing that medication in the long term that we can get them to our ideal goal of endoscopic remission. But that might take time. But the patient's feeling better, there's that hope in them that they can continue with that same therapy, they're going to continue to improve and later when you reassess them by endoscopy or ultrasound or cross-sectional imaging, that we've achieved that goal. And if they haven't achieved it, then going back to STRIDE-II guidelines that we must reassess. And why did they not achieve that? But it's a discussion that we need to keep having, bring them back to clinic, if they achieve symptomatic remission, that's more of a hope for the patients that we can continue to get to our ideal goal in the long term.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: If I could also add along with what Dr Abraham is mentioning, we remember with inflammatory bowel disease, it's not a one size, one drug, one dose, one treatment for all strategy. Recognizing that each individual patient suffers from Chron's disease in their own ways. And so, it must be shared decision making because I can't predict which of my therapies in the medicine cabinet will my patient respond to. To be able to gain that trust, understand the patient's goals, incorporate that for each individual patient, it must be through shared decision making, because, again, you're going to trial therapies out and hope that it works, we can't predict if it'll work yet or not. One day, I hope we can predict that. That's precision medicine.
David P. Hudesman, MD: I completely agree. And it's important to have these discussions what I found helpful upfront before you even get into the therapies, right? You must really discuss this first and then we could move into, "OK, what are our different options?" And I guess, Dr. Abraham, when we're talking about our different options.
Transcript Edited for Clarity