Identifying Progressive, Relapsing IBD
JUNE 25, 2020
Miguel Regueiro, MD: David, Marla mentioned the progressive and relapsing nature of IBD [inflammatory bowel disease] and how we look at severity, disease grading, and complications. Tell us about how you approach a patient in terms of the relapsing, progressive nature. How do you define that disease severity?
David T. Rubin, MD: Thanks, Miguel. I want to add to what Marla has already mentioned, which is that there's heterogeneity to inflammatory bowel disease. While we acknowledge that there are the 2 major types of Crohn disease and ulcerative colitis, within each of those, there are many different types. And that's not just based on the phenotype or the pattern of inflammation but also based on the behavior of the disease over time and the presence of extraintestinal manifestations, which can impact the overall progression or consequences of the disease.
When we've talked about the classic IBD being relapsing and remitting, meaning that it's at times very active, the patient is symptomatic or suffering from complications, and at other times is in remission and doing well. What we've also come to appreciate is that many patients may have more of a progressive course where they have never achieved more control, which we'll get into later during this discussion, but the disease is smoldering along and progressing over time.
As a treating physician, or as a clinician taking care of these patients, the challenges for the patient who's had progression, by the time you're involved in their care, either making the diagnosis, managing them, or taking over their care, a lot of the time, there has been enough damage that you can't have much utility with our existing medical therapies. When we approach these patients, you have to take a careful history to fully understand when the disease may have started to appreciate the types of patterns that may have occurred over time, asking about whether the disease has actually been in remission since they were initially diagnosed or not and separating out the condition, its activity—how active is it at a particular moment—from its severity, which we talk more about for prognosis, which Jessica Allegretti will talk a little bit more about.
The activity refers to how much inflammation there is in the bowel and what the other measures are of how the disease is currently affecting that individual, whether it be their laboratory values like elevated inflammatory markers, anemia, or a low albumen. Whether it be endoscopic findings, which are very important, that will tell us more about how active the inflammation is. As well as whether there's been ongoing damage to the bowel and what the extent of that disease is; or other radiographic findings, whether it's the traditional cross-sectional imaging or the emerging ultrasound assessment of the bowel. Those are all ways to know how sick the patient is. Then there's the functional assessment. Are they able to function? Are they able to get around and go to school or work and do the things that they need to do? That all factors into what's going on with the patient right now.
To understand whether this has been progressive or maybe relapsing and remitting, the next part is what's happened before you met them or what will happen as you've been treating this patient. Are you observing that there are times where they get in very good control, and they are much more functional and—of course we have objective measures—their disease is managed?
When we think about the severity, that impacts not just how you treat their active disease, but also it impacts how you think about treating them over the long term. While Jessica will get into some more of the details here, what I've been working on with my colleagues [at the University of Chicago Medicine] is thinking more about what is defining for each individual patient. Is this patient severely active or in remission at the time we're making decisions? What is their risk of progression to complications like bowel obstruction, need for surgery, hospitalization, or disability? And making decisions about how we maintain their management, and very importantly, how we monitor them and stratify their follow-up.
For a patient who is easily controlled with your initial therapies, or who, after some fine tuning, is doing quite well and who has a milder prognosis, and that's something Jessica will help us understand, you might bring them back less often. You might have a more relaxed strategy to check laboratory test results regarding the disease activity or repeat scopes or imaging. On the other hand, in somebody who's high risk, or who took a longer time to get under control, or who has other features that make you worried about them, including socioeconomic factors, these are people you want to stratify for more frequent follow-up.
You build in the understanding of whether this person has more of a progressive, smoldering, complicating disease, a relapsing or remitting course, the treatment history, and then factor that into the way you're going to monitor and continue to stay on top of things. It's a much more proactive approach that requires multiple dimensions of considerations than we've used in IBD in the past, and it's an important message. This lends itself nicely to that emerging consideration of treating to a target, which means serial monitoring and adjusting therapies to try to get where you need. And you can adjust that, both the target and how you monitor them, based on how sick they are now, what's happened to them before, and what will happen to them in the future.
Transcript Edited for Clarity