Treating a Low-Risk Inflammatory Bowel Disease

Transcript: Miguel Regueiro, MD: Let's shift a little bit to treatment, as far as how you approach treatment both from a medical standpoint and then, ultimately, how we look at surgery. Jessica, we don't talk a lot about the milder end, but tell us a little bit about your approach, especially for the community physicians not at tertiary centers. How do you approach mild UC [ulcerative colitis] and mild Crohn disease?

Jessica R. Allegretti, MD, MPH: It is important to remember that these patients do exist. We tend to focus a lot on the severe, very sick patients, but there are going to be patients who have mild disease, who are at low risk for complications. Using some of the tools we've already discussed to identify who is truly low risk versus not is important up front when you're assessing the patient. For patients with ulcerative colitis mild disease, there may still be a role for both oral and rectal 5-ASA [aminosalicylate] therapy to both induce and maintain remission.

You can use oral or rectal budesonide. In your patients with Crohn disease, especially those with mild isolated ileal disease, you could think about budesonide, of course, as well. The biggest take-home point with these types of patients, though, is if you feel very comfortable that they're low risk, that's fine, but you still need to perform everything we've been discussing as you would for your high-risk patients: with a treat-to-target metric. You don't just want to put the patient on a 5-ASA [aminosalicylate] regimen and send them on their way, and then a year later, they've been on, say, prednisone 3 or 4 times. That’s not a low-risk patient. Still assessing these patients, especially up front, to ensure that you induced remission and you are maintaining appropriately is critical because a lot of these patients, especially those with isolated rectal disease, often get put into a low-risk box, and they’re continually on rectal steroids or courses of steroids because people don’t want to advance those patients to biologics because their disease is somewhat more limited. Those patients can have severe disease too, and it can have bad outcomes. Following those patients just as closely as you would any other with a treat-to-target metric is important.

Miguel Regueiro, MD: You brought up a good point with ulcerative colitis. The way I look at ulcerative colitis is this: it’s almost 2 flavors, and I don’t want to simplify it, because it’s multiple diseases. But the first half is those who respond quite well to 5-ASA [aminosalicylate] and don't seem to progress, and then the other half for whom [aminosalicylate] is not enough, and you do need to monitor and see early that these patients are responding. Then, Crohn disease is a little bit trickier. Three-quarters, two-thirds probably need some type of a biologic, immunologic therapy from the start. There are patients in the community who are milder, so these are people who maybe aren't referred to us in tertiary centers. For the majority of the patients, they have these high-risk factors, Jessica, that you already mentioned.

Transcript Edited for Clarity