Goals of Therapy for Inflammatory Bowel Disease

Transcript: Miguel Regueiro, MD: David, for a couple of minutes, let's focus on goals of therapy. You did a nice job at introducing this concept, but when you talk about goals of therapy in IBD [inflammatory bowel disease], tell us your thoughts. You've been involved in the ACG [American College of Gastroenterology], AGA [American Gastroenterological Association], and many of the guidelines around this, but what are your thoughts on goals of therapy in IBD?

David T. Rubin, MD: Well, the first thing is that the goals of therapy are not just for the clinician or the provider. They're also for the patients, and it's important that, when we review these goals, we remember as well that, by telling the patient what our goals are, we can all be on the same page. We've learned that, even when we think that's happening, a lot of times, our patients' expectations are different than ours, and that leads to a lot of confusion.

The goals are divided into ways to make sure we're getting people well initially, and then ways that we can keep them well and prevent complications. The first goal is to make sure, as you heard very nicely so far, that we make an accurate diagnosis, not just calling it Crohn disease or colitis, but as we've discussed, knowing how active the disease is, as well as what the prognosis is for that patient and what the other factors are that might influence the prognosis, like extraintestinal manifestations, significant family history, or other factors. It also includes making sure that that diagnosis is accurate in the sense that you're comfortable that this truly is chronic IBD. Remember the old adage that time is on the doctor's side. These days, we might modify that to say time is on the provider's side or the team's side, but the point is, when you're not sure, coming back and repeating an examination after an interval often gives you the answers you're looking for.

The second goal is about inducing remission, and the term remission has various definitions. What we're trying to do initially is to make the patient feel better, so symptom improvement directly correlates to quality of life. Secondarily, and importantly, we've adopted this important consideration that, in addition to symptom improvement, we want objective measures that the disease has in fact been turned off or shut down long enough that the body can start to heal and we can get to a place where we know that the inflammatory condition is under better control. Describing to patients what that is and what the expected time course might be based on different treatment strategies is very important.

It also includes making sure that you have a plan for follow-up to assess that. When would you reassess the patient to know that they're feeling better, and when would you repeat laboratory tests, repeat a scope, or repeat other noninvasive markers to know that you've made obvious progression here?

The third goal, after you've achieved remission, is maintenance. This is a chronic condition. As we've discussed, chronic conditions can progress over time or they can relapse. Maintenance is about prevention of relapse, prevention of progression over time, and a lot of times, people forget that or think that maintenance is about treating intermittently for active disease. That's not what it's meant to be. What we want is a sustained remission, which means that the patient is well consistently over time as you follow them out. Ideally, that's forever, but we recognize that may not be the case. Our goal is to get patients to a maintenance strategy that uses the least amount of therapy that is necessary and effective and that is safe.

That leads to the next part of our goals, which has to do with assessing and preventing complications from both the therapies as well as from the disease. Increasingly, in some of our guidelines, this includes assessing patients for the risk of anxiety and depression, which coexist and are increased in our patients with IBD. It also includes preventing cancer by scheduling patients for their screening and surveillance colonoscopies and assessing any potential impacts of therapies on the patient, both direct toxicity from treatments, which fortunately is rare with existing therapies but is still important, as well as preventing infectious diseases that might be prevented by vaccinations, which has become an important focus of what we're doing and is something we have to think about. If you move through the goals in a systematic fashion where you get somebody into remission that is objectively confirmed, you sustain remission over time in a strategy of maintenance that is effective, you communicate effectively with the patient so they understand what you're trying to do, and you work to make sure that you're preventing complications, then you're going to have the entire picture of managing this chronic disorder in a way that's going to change outcomes, change the natural history of the disease, and hopefully keep the patient very healthy.

Transcript Edited for Clarity