Examining the Long-term Clinical Evidence of Therapies for Inflammatory Bowel Disease in Bio-naïve Patients - Episode 8

Selecting Treatments in Patients With EIM

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Anita Afzali, MD, David Hudesman, MD, and Maia Kayal, MD, discuss how extra intestinal manifestations (EIM) affect therapy strategies for Crohn’s Disease (CD) patients.


David Hudesman, MD: Let’s pivot to another subgroup of patients. Miguel brought this up when we were talking about what factors are important: EIMs, or extraintestinal manifestations. Anita, how do you incorporate that into your treatment?

Anita Afzali, MD: Great question. We experience this with our patients frequently. EIMs are common, unfortunately. It’s important for us to understand which EIM we’re discussing and differentiating. Is this an arthropathy that’s parallel in bowel disease activity? Or is this a skin dermatologic manifestation, such as erythema nodosum, that parallels bowel disease activity and controls the bowel and the gut so the EIM will improve? In that regard, it’s important to focus on active inflammation. Whatever treatment you select will control that inflammation, and then the EIMs also improve.

Sometimes it’s hard to tease out because the gut is active, their joints are or their skin is painful, or an EIM doesn’t necessarily parallel bowel disease activity. Fortunately, in our medicine cabinet we have therapies that have approved indications for joints, the gut, and the skin. I select my treatment by differentiating if this is paralleling bowel disease activity…. From that, I determine which treatment to choose for that indication. For example, JAK inhibitors are a consideration. In this situation, I’d go to a TNF [tumor necrosis factor] frequently if my patient is also suffering from an extraintestinal manifestation, specifically arthropathy. For psoriasis, this is where you’re thinking of IL-12/23 or p19. This is how I differentiate it. Most often we get it right, but sometimes we might not. That’s when you go back and make sure it’s a multidisciplinary discussion with the appropriate colleagues, whether it’s rheumatology, dermatology, ophthalmology, or whomever.

David Hudesman, MD: This is an area where we need more data. But with spondyloarthropathies, I agree completely. UC [ulcerative colitis] and Crohn are where we’re using TNF or JAK inhibitors. Another thing that we don’t do is ask about them and screen. When I started I would ask, “Do you have joint pains?” No, but then you’re examine them and they say, “My back hurts.” They don’t think the back is a joint. We ask some other simple questions. Do the joint pains get better or worse with activity? Do they have that morning stiffness? These simple questions don’t take a long time, but they could help you say, “Maybe we should have you speak to a rheumatologist,” or “Maybe we should think about this a little more before we throw you on a more targeted therapy for your bowel.”

Maia Kayal, MD: Some of the therapies we use can unmask some of the extraintestinal manifestations in our patients. We don’t do a good job asking up front, and we’re doing a bad job following up about how their extraintestinal manifestations are doing on some of these therapies. I’ve had several patients who started vedolizumab for colonic Crohn [disease] or ulcerative colitis, and it unmasks their arthropathy. Then you’re backtracking. Sometimes you might add a sulfonamide, send them to a room, or change that drug because you want to get the most bang for your buck. If you can, you want to hit both indications with 1 agent. We don’t do a good job asking up front, and we definitely don’t do a good job asking in follow-up.

Anita Afzali, MD: We don’t do a good job asking up front. Are they focusing on their joints because their bowel symptoms have improved? It’s not necessarily unmasking, but are we focusing on new symptoms because their diarrhea or abdominal pain has improved?

Transcript edited for clarity.