Combined Clinics – Combined Management Strategies

Alexis Ogdie, MD, Adam Chefeitz, MD, and Joseph Merola, MD, gathered at the 2023 virtual Interdisciplinary Autoimmune Summit to discuss combined clinics and how a monodisciplinary, siloed approach can lead to unmet needs in the care of patients with immune-mediated inflammatory diseases (IMIDs).

They recommended comanagement strategies, because patients with IMIDs are typically at a higher risk of developing other autoimmune conditions. The experts discussed the advantages of combined clinics in the treatment of autoimmune diseases.

Dr Merola is the vice-chair of Clinical Trials and Innovation at the Brigham and Women’s Hospital in Boston, Massachusetts. Dr Ogdie is an associate professor of medicine at the Hospital of the University of Pennsylvania in Pennsylvania, Philadelphia. Dr Cheifetz is the director of Center for IBD at the Beth Israel Deaconess Medical Center in Boston, Massachusetts.

Not only did the experts delve into the benefits of collaborative multidisciplinary care in IMIDs, but they also explored the potential dermatologic and immune-mediated reactions to anti-tumor necrosis factors (anti-TNF). Dr Ogdie and Dr Merola also reviewed the potential role of combination biologics in IMIDs.

Referring to a case of an adult male with psoriatic arthritis and psoriasis who was also experiencing intermittent diarrhea and abdomen pain without mucus or blood, Dr Merola pointed out certain red flags to be considered. These include rectal bleeding, iron deficiency, nighttime symptoms, weight loss, and family history of colon cancer or inflammatory bowel disease (IBD). However, he cautioned to never blindly assume that symptoms are a flare of IBD. 

Dr Ogdie recommended reactive therapeutic drug monitoring (TDM) of biologics in IBD. It was more cost-effective as well as associated with better therapeutic outcomes than empiric anti-TNF therapy optimization. “And then there is proactive TDM,” Dr Merola said, referring to a study published in the Current Opinion in Rheumatology coauthored by Dr Cheifetz and Konstantinos Papamichael, MD.

 While reactive TDM is currently considered as standard of care, proactive TDM is another therapeutic strategy for optimizing anti-TNF therapy in IBD. “Recent data suggest that proactive TDM, with the goal of targeting a threshold drug concentration, is associated with better therapeutic outcomes when compared with empiric dose escalation and/or reactive TDM of infliximab or adalimumab,” Dr Merola said. “Also, proactive TDM can also efficiently guide infliximab de-escalation or discontinuation in patients with IBD in remission.”

Dr Cheifetz chimed in saying “Proactive TDM is the way to go because why wait till we lose all response to start monitoring?”

When treating patients with moderate-to-severe Crohn's disease, patients treated with infliximab plus azathioprine or infliximab monotherapy “were more likely to have a corticosteroid-free clinical remission than those receiving azathioprine monotherapy,” Dr Cheifetz said.

Another systematic review and meta-analysis into dual biologics or small molecule therapy for treatment of patients with IBD found that higher quality combination of therapies was associated with a significant improvement in the quality of data.

Patients with IBD are often at risk for certain malignancies, such as developing melanoma and nonmelanoma skin cancer (NMSC). A study based on a cohort of 108,579 patients with IBD taken from LifeLink Health Plan Claims database between 1997 and 2009, found that IBD was associated with an increased incidence of melanoma (95% CI). This risk was greatest among individuals with Crohn disease (IRR, 1.45; 95% CI, 1.13-1.85; adjusted HR, 1.28; 95% CI, 1.00-1.64). Patients with IBD were also at higher risk of developing nonmelanoma skin cancer (IRR, 1.46; 95% CI, 1.40-1.53) and again, the risk was greatest among those with Crohn disease (IRR, 1.64; 95% CI, 1.54-1.74)

“Patients with IBD should be counseled and monitored for skin cancer is the takeaway here,” Dr Merola summarized.

In preventive care in IBD, Dr Ogdie gave shout-out to American College of Gastroenterology (ACG) guideline statement that strongly recommends that patients with IBD —both ulcerative colitis and Crohn disease—should undergo screening for melanoma independent of the use of biologic therapy. She also highlighted the ACG statement that patients with IBD on immunomodulators such as 6-mercaptopurine or azathioprine should undergo screening for NMSC while using these agents, particularly over the age of 50.

—Priyam Vora

Reference:
Ogdie A, Cheifetz A, and Merola J. Combined clinics: Co-management strategies. Interdisciplinary Autoimmune Summit. April 26-28, 2023. Virtual.