As part of the Advances in Inflammatory Bowel Diseases (AIBD) conference, I joined the Fellows Session I: Translating the Language of IBD to the Patient. The session was co-chaired by Christina Ha and Lisa Malter and was targeted at Fellows. For those who aren’t familiar with the medical training system in the United States, a Fellow is a doctor who has completed their residency (specialist training programme), and elects to complete further training in a speciality, such as gastroenterology.
There were a number of distinguished healthcare professionals from the IBD community involved in moderating and facilitating different aspects of this session, covering: different frameworks for effective partnering between IBD providers and people with IBD; how doctors can help to inform and empower people with IBD; choosing the optimal IBD therapy as a shared decision-making process; and the goals of caring for people with IBD. Attendees were split into different breakout groups for discussion at several time points during the session, with groups consisting of up to 10 Fellows and one member of the conference session faculty.
Dr. Regueiro discussed a framework for choosing the optimal IBD therapy, highlighting the concept of ‘treat-to-target’. ‘Treat-to-target’ is based on finding and defining appropriate treatment targets, using available evidence. For certain conditions, like high blood pressure, there are very clear targets which should be met, such as having a systolic blood pressure (top blood pressure number) less than 140 mmHg; since otherwise, you are at a higher risk of a stroke or heart attack. ‘Treat-to-target’ in conditions like IBD are a little more challenging, because the ‘target’ is less clear or straightforward. For example, some doctors say that it should be the normalisation of biomarkers (e.g., fecal calprotectin in range), whereas others argue for mucosal healing (disease activity is not seen during an endoscopy procedure), and histological healing (complete recovery of the digestive tract, with absence of inflammation or structural changes under the microscope).
Dr. Regueiro then went on to summarise the current IBD therapy landscape, prompting for the choice of biologic or small molecule to be personalised for every individual person with IBD. He recognised the need to start biologic/small molecule therapy earlier, particularly for those at high risk for rapid progression. He outlined four key groups of treatment falling under the biologic/small molecule categories as we enter 2021:
Anti-TNFs (e.g., adalimumab, certolizumab, golimumab, infliximab);
Anti-IL-12/-23 (e.g., Ustekinumab);
Anti-α₄β₇ integrin (e.g., Vedolizumab);
JAK inhibitors (e.g., Tofacitinib).
An important part of the conversation around the most suitable treatment for people with IBD relates to treatment safety. Dr. Regueiro highlighted the importance of open and honest conversations between doctors and people with IBD, and the need for transparency in evidence. During his presentation, he presented a new safety pyramid of different treatment options based upon available evidence, including conventional treatments such as steroids and thiopurines. Regueiro stated that this safety pyramid was most relevant at the time of AIBD 2020. The safest treatments were vedolizumab and ustekinumab. These were followed by single treatment with anti-TNFs (e.g., adalimumab, certolizumab, golimumab, infliximab) and tofacitinib. Thiopurines (e.g., azathioprine, 6-mercaptopurine, thioguanine) and combined thiopurine/anti-TNF treatment then followed, respectively. Steroids were seen as the least safe treatment for people with IBD.
Laura Raffals spoke about the goals of caring for people with IBD, emphasising the privileged position of healthcare professionals to be able to support people with IBD. She also highlighted the importance of a multi-disciplinary approach to care, recognising that the doctor alone is inadequate. As part of the team, you ideally need nurse practitioners/specialists, physician assistants, medical assistants, pharmacists, dieticians, advanced practice providers, and social workers, to ensure that care is holistic and meets the needs of every individual person. This also needs to include those outside of gastroenterology, including the likes of other specialists (e.g., rheumatology), surgical teams, primary care providers, radiology, pathology, behavioural health specialists, and support service providers, to name but a few.
Discussion continued about the need to think about preventative care, such as immunisations, bone health and cancer, and how this should be optimally achieved with other healthcare professionals and people with IBD. Ideally, healthcare maintenance should be co-managed between specialists and primary care providers; however, this is not always the case, leaving people with IBD feeling ‘lost’. Specialists in those circumstances recommend checklists to help ensure preventative measures are considered from the outset.
Access to care also needs to be fit for purpose, combining in-person care, telephone care, urgent care, support services, electronic access to information, data, and services, and education. In terms of looking forward, we have already seen a glimpse of what the future of healthcare will look like as a result of the COVID-19 pandemic. The likes of remote monitoring, telehealth and self-scheduling are likely to increase, and should be used in the right situations, dependent on the specific needs and wishes of people with IBD. Laura finished by saying, “patients are expecting care on their terms”, which is indeed a fitting way to summarise the changing healthcare provider-patient relationship as we move in 2021 and beyond.
