A Personalised Pathway to Optimal Care for Inflammatory Bowel Disease

Author: Hannah J. Moir

Support statement: The writing and publication of this news feature was supported by Viatris, who were not involved in the creation of this content.

Over the last decade, the treatment landscape for Crohn’s disease and ulcerative colitis has significantly changed. The introduction of biologics and small molecule therapies has led to the shift in focus from achieving symptomatic remission to attaining deep remission, particularly through the early utilisation of anti-TNFs and biologics. However, healthcare professionals  face challenges in selecting the most appropriate treatment for each patient.

To address this difficulty, The International Organisation for the Study of Inflammatory Bowel Diseases (IOIBD) developed the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) guidelines in 2021.¹ These guidelines establish therapy targets, offering specific treatment goals for Crohn’s disease and ulcerative colitis in both paediatric and adult populations.¹ The STRIDE guidelines advocate for personalised decision-making and outline short-term targets such as symptomatic response and normalisation with biomarkers such as C-reactive protein.¹ Notably, the long-term target is directed towards achieving endoscopic healing, normalisation of quality of life (QoL), and the absence of disability.¹

PERSONALISING TREATMENT GOALS IN CROHN’S DISEASE AND ULCERATIVE COLITIS CARE

The international treatment guidelines highlight the need to select the appropriate therapy early to avoid steroid use or enable early steroid sparing, and, when necessary, surgical intervention.^2,3,4 This involves assessing factors that may impact the pharmacokinetics of immunomodulators, biologics (including anti-TNFs), and other monoclonal antibodies such as anti-integrins.⁵ Anticipating the need for dose escalation is also important, considering factors such as the presence of anti-drug antibodies, concomitant use of immunosuppressives, low albumin serum, high C-reactive protein, and human leukocyte antigen status.⁵ Once escalated on a biologic, patients should undergo close monitoring and be de-escalated when appropriate. However, addressing the loss of response to therapies is vital for subsequent therapy efficacy.⁵ Regardless of the treatment sequence, careful monitoring for early signs of non-response and timely switching to another active therapy is essential.⁶ Current recommendations for inflammatory bowel disease (IBD) consider the severity of the disease, prioritising (for most patients) first-line therapies like anti-IL-12/23 or anti-TNFs such as adalimumab or infliximab, often in combination with thiopurines or methotrexate.⁷ Additionally, janus tyrosine kinase (JAK) inhibitors are considered for second-line therapies.⁸

Emerging Therapies and Treatment Strategies for Inflammatory Bowel Disease

Despite treatment efficacy, comorbidities, contraindications, and circumstances associated with anti-TNFs need careful consideration. In cases of moderate to severe Crohn’s disease, alternative options like anti-integrin vedolizumab, IL-12/23 (ustekinumab or risankizumab), or JAK inhibitors could be considered.⁹

A recent review published in October 2023 highlights the emergence of new and emerging therapies for patients with moderate-to-severe IBD who have not responded to conventional treatments.⁵ While acknowledging the necessity for long-term safety and efficacy data, the review introduces additional treatment options. These include subcutaneous anti-TNF infliximab and oral anti-TNFs, providing alternatives to intravenous anti-TNF agents.⁵ Additionally, the review explores the potential of anti-adhesion agents and anti-ILs for preventing inflammation, as well as JAK inhibitors and sphingosine-1-phosphate receptor modulators.⁵ These emerging medications, along with the biosimilar alternatives, hold the potential to support current IBD treatment strategies, offering valuable alterations to traditional approaches.

For patients refractory to steroids, a proposed algorithm for those with acute severe ulcerative colitis suggests considering immunosuppressive cyclosporine or anti-TNF infliximab as a mainstay for naïve patients when steroids fail, taking into account the risk-benefit ratio for the patient. Non-naïve patients can be treated with JAK inhibitor tofacitinib, bridging in the short-term with cyclosporine and transitioning to maintenance in combination with anti-integrin vedolizumab or anti-IL-12/23 ustekinumab.¹⁰

The current international guidelines for IBD outline first-line and second-line therapies, taking into account patient comorbidities and personalised treatment goals when selecting therapeutic targets. The patient pathways aim to provide fair access to evidence-based IBD treatment.¹

It is important to note that these points are based on recent findings, and healthcare professionals should make treatment decisions in accordance with their local authority’s regulatory guidelines and approvals.

ENCOURAGING PATIENT INVOLVEMENT AND CONSIDERING INDIVIDUAL PATIENT FACTORS IN

When considering treatment options for IBD, it is crucial to take into account patient-specific factors such as cost, access, and where applicable, insurance-related barriers. These factors can have an impact on patients’ QoL. Therefore, having collaborative discussions and making shared decisions around newer therapies, decisions, and prices may be time-consuming yet beneficial to providing the best care possible.

Taking a broader perspective, this should consider the most appropriate drug based on mechanisms of action, associated risks (e.g., young age, less than 30 years of age, extensive bowel involvement, perianal or severe rectal disease, and penetrating or stenosing phenotype), patient preferences, dosage, timing, and monitoring. Consideration of these options is imperative for comprehensive and patient-centred IBD care.

Importance of Shared Decision-Making in Inflammatory Bowel Disease Treatment

Emphasising the importance of patient involvement in treatment decisions is essential. Shared decision-making should incorporate patients’ perspectives on costs, administration convenience, concerns about side effects and the risk of adverse events, co-morbidities, and special situations that impact the best indication for their given disease and circumstances.¹¹ Patients’ goals and concerns are highly variable and related to the course and management of the IBD, including clinical course and management, IBD symptoms, disease state, medication types and concerns, and psychosocial and QoL-impacting emotions and effects on daily living.¹¹

The choice of treatment should be made together with the patient, guided by clinical judgement, national guidelines, and individual patient factors.

Incorporating Patient Factors in Treatment Decisions

A recent review published in September 2023 recommends individualised treatment approaches based on patient-specific factors. The authors suggest disease characteristics (severity of the IBD), individual risk factors, extra-intestinal manifestations, other health issues such as patient co-morbidities (e.g., infection risk, cancer risk), patient age (including childbearing age and pregnancy), treatment cost, previous exposure, and patient preferences (including whether intravenous, subcutaneous, or oral), should be considered when determining the best treatment approach.¹²

Patients should have an active role in choosing their treatment, and if multiple drugs are suitable, the least expensive option should be selected.

A 2023 survey on patient preferences and desired treatment outcomes demonstrated that patients prefer preventing surgery, achieving long-term clinical remission, improving QoL, reducing urgency, and improving labour rates.¹³ The survey also highlighted the importance of understanding desired treatment outcomes and explicitly discussing and considering these within a shared decision-making process.¹³

An Integrated Multidisciplinary Approach for Optimal Care

A session at United European Gastroenterology (UEG) Week 2023 entitled ‘Therapy update: The integrated approach to optimising care of the patient with IBD’ considered that an integrated multidisciplinary approach is needed to optimise care for patients with IBD. This approach involves a holistic model of care that can improve patients’ physical and mental health, reduce complications, and decrease healthcare costs.

The approach involves a gastroenterologist-led multidisciplinary team, including IBD nurses, a surgeon, psychologist, dietician, pharmacist, and other members as needed. The team provides targeted resources to patients, ensuring structured monitoring, active follow-up, patient education, and prompt access to care.

Finally, the European Crohn’s and Colitis Organisation (ECCO) care project is currently looking into the importance of ‘national IBD patient pathways’. This is a concept that was first implemented in structural oncology pathways and is focused on reducing the time from suspected cases of IBD through to the initiation of therapy.¹⁴ These pathways take into account the structure, process, and patient outcomes, and involve shared decision-making.¹⁴ The aim is to use structured monitoring, active follow-up, patient education, and timely access to care to improve outcomes for patients with IBD. The results of this project will be of importance in determining the quality standards for optimal IBD care, and we eagerly await its outcomes in the near future.

In summary, the key principles for optimal IBD treatment include personalisation, early intervention, and consideration of patient priorities and patient-specific factors such as disease activity and severity, sequence of treatment, and special populations, such as older patients and those considering family planning. Ultimately, the focus should be on what matters the most to the individual.

References

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2. Lamb CA et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. 2019;68(Suppl 3):s1-106.
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14. Myrelid P. National IBD pathways. 2023. Available at: https://www.ecco-ibd.eu/publications/ecco-news/item/2023-2-national-ibd-pathways.html. Last accessed: 10 January 2024.