Optimizing Treatment Strategies to Manage Inflammatory Bowel Disease - Episode 7

IBD Treatment Options for Patients With Low-Risk Disease

September 9, 2021
Remo Panaccione, MD, FRCPC

Edward Loftus Jr., MD

William Sandborn, MD

Jessica Allegretti, MD, MPH

Initial IBD therapy for a patient with low-risk disease and measuring treatment response on initial therapy.

Remo Panaccione, MD, FRCPC: Ed, we fast-forwarded to patients with biologics and those patients with more severe disease—however we want to define that—but we still have these low-risk patients in our practice and our colleagues have them in their practices. What is your approach to treating low-risk patients? Let’s focus on Crohn’s disease. I think people are pretty comfortable regarding ulcerative colitis. What do you do for those patients? Do not mind me, because he’s going to say, “There are no low-risk patients.”

Edward Loftus Jr., MD: No.

William Sandborn, MD: They are not.

Jessica Allegretti, MD, MPH: I am going to say there is no therapy.

Edward Loftus Jr., MD: I think about 20%. The natural history studies show that at least 20% percent of patients never need surgery, right? They have nonprogressive Crohn’s, and they tend to be older at diagnosis; they tend to have colonic disease. Not everyone always has this image of colonic Crohn’s as these terrible, deep rake ulcers. No, a lot of colonic diseases just have this ulcer superficial erosion. I think the patients with older onset colonic disease tend to not develop strictures or internal fistulas. Those are patients that can be treated with just a tapering course of a steroid, either budesonide or prednisone, and then observe and see how they do. If you do not do that, then the key is monitoring. The key is educating that patient, the patient who’s a little, I guess now, in this day and age, we would say biologic hesitant. The patient that doesn’t want to go on a biologic; we need to say, “OK, we will do this. We will just give you the tapering course, but then you have to come back at X time.” That is, we will see them at 6 or 12 months and reassess them to make sure they do not have progressive disease.

Remo Panaccione, MD, FRCPC: I think that that is the key. Even if you are using conventional therapy, you should not get outside of that cornerstone of monitoring their disease. But then the question comes back to us. How often, Jessica, would you monitor somebody? That is put on the table; somebody with colonic Crohn’s disease has significant, sufficient symptoms to go on a course of prednisone, but has no other high-risk factors. Do you monitor them once a year for recurrence? Do you monitor them every 6 months? What do you do?

Jessica Allegretti, MD, MPH: I say I would start to assess what tools I can use for this patient, right? I would hopefully have gotten a baseline fecal calprotectin to see if that is something I can use for a patient like that. If they have colonic disease—presumably yes—then, certainly, I would continue to follow that. I would follow post-steroid course to see: Did we actually do what we thought we did? Did they normalize in addition to their symptom improvement? Was that a fairly accurate tool to treat them? Usually, in the beginning, I always tell patients, “If you want, we are going to continue up there, and I am going to be watching you like a hawk.” That is part of the deal, because we do not know— especially as I’m getting to know somebody—I do not know your disease course yet or how your disease is going to behave. I would say, at a minimum, I would be getting fecal calprotectin and checking in with that patient every 6 months to make sure we are not starting to see an increase, if they remain asymptomatic.

Of course, if any symptoms start to creep back, you are starting to do things earlier. But ideally, you would like to identify problems before they become real problems. If that patient had now gone for 2 years and we have not seen anything, you might start to spread that out. Certainly, in the beginning, when I am getting to know somebody and we have gotten them well—we have induced them with a steroid course, for example—I am going to continue to watch them fairly closely at a minimum of every 6 months. Sometimes, I might even check in every 3 months in the beginning just to make sure I am not missing something. That this is not a patient who has a more aggressive phenotype and I just was not aware yet. Then, certainly, once their disease has proven itself, I would certainly spread that out and at a minimum, have an annual visit with a patient like that.

Remo Panaccione, MD, FRCPC: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our eNewsletters to receive upcoming Peer Exchanges and other great content right to your inbox. I am sure you will see the folks in front of you on future programs. With that, thank you very much.

Transcript edited for clarity.