Endoscopic monitoring key in ‘treat-to-target’ approach for IBD
BOSTON – Using a treat-to-target approach for managing inflammatory bowel disease can be an important tool for improving both short- and long-term outcomes, according to Marla Dubinsky, MD, chief of gastroenterology, hepatology and nutrition and co-director of the Susan and Leonard Feinstein IBD Clinical Center at the Icahn School of Medicine, Mount Sinai, New York City.
In a presentation given at the Interdisciplinary Autoimmune Summit, Dubinsky argued that gastroenterologists should consider more objective measures like endoscopic disease monitoring and therapy modification in addition to patient-reported clinical outcomes to avoid the eventual progression to the development of serious complications in IBD.
“Yes, your patient needs to feel well, but they also have to have endoscopic remission,” Dubinsky said. “At the time of colonoscopy, they have to have normalization. That is a big change in just asking a patient how they’re doing.”
The “treat-to-target” approach involves predefined treatment targets after consultation with the patient. During this management plan, disease activity is regularly monitored, and therapy is modified until that target is reached. Dubinsky said it is not a novel concept in the treatment of other chronic diseases and gave the example of rheumatoid arthritis, for which controlling disease activity can alter the progression to joint damage.
When treating patients with IBD to a targeted outcome, Dubinsky said regular endoscopic observation is key to ensuring the patient’s current therapy is effectively promoting mucosal healing, which will in turn promote significantly better outcomes for the patient.
Dubinsky said determining a patient’s risk for disease prognosis through a number of measures, including endoscopy, as well as CRP and fecal calprotectin tests, at induction can help clinicians optimize therapy and ensure patients are getting the right amount of medication.
Using computer models, physicians can map out how much medication each patient will need to ensure they stay above effective dosing levels. Studies have shown that this therapeutic drug monitoring reduces treatment failure, as well as IBD-related surgery and hospitalization, according to Dubinsky.
One study Dubinsky pointed to as an example of treat-to-target’s efficacy was the CALM study, published in 2017. In the study, 240 patients with Crohn’s disease were randomized to either treat-to-target or conventional treatment escalation. The study found that 45.9% of patients in the treat-to-target cohort achieved endoscopic remission and had no deep ulcerations compared with 30.3% of patient in the conventional treatment cohort.
Despite showing positive results, Dubinsky noted that current studies have been limited to 52 weeks, making it difficult to give patients assurances about improvements beyond one year.
“The challenge now is to drive treat-to-target from concept to clinical practice by addressing key barriers to practical implementation,” Dubinsky said. “We definitely need more prospective studies, and treatment targets for IBD will continue to evolve.” – by Alex Young
Dubinsky M. “Treat to Target – Including Endoscopic Healing.” Presented at: Interdisciplinary Autoimmune Summit; April 27-29, 2018; Boston, Mass.
Disclosures: Dubinsky reports that she is a consultant for AbbVie, Boehringer Ingelhein, Celgene, Eli Lilly, Genentech, Janssen, Pfizer, Prometheus, Salix, Shire, Takeda, and UCB.