Dr Abreu reviews her presentation from the the Advances in Inflammatory Bowel Diseases 2020 virtual meeting on applying precision medicine today and in the future in the practice of caring for patients with inflammatory bowel disease.

Maria Abreu, MD, is director of the Crohn's and Colitis Center at the University of Miami Miller School of Medicine.

TRANSCRIPT:

Hi, everybody. I'm Maria Abreu. I'm at the University of Miami. I'm director of our Crohn's and Colitis Center. Millie, Steve, and Miguel have asked me to talk about applying precision medicine in your practice today and tomorrow. I've just given that talk.

I hope that if you didn't listen to it, you will eventually listen to it because I've given that a lot of thought. Right now, what are we doing in our offices? We see a patient that has IBD and we're basically putting them through serial medications.

If we had to be honest, often these are guided by what he insurance company wants us to do. I think we had this opportunity to think through how we decide what medicine we're going to use in what person. It's led me to think through, "Why is it that a person responds to a particular medicine? What are the things that drive that?"

Some of it is going to be the genetics of that person. Some of it's going to be the microbiome of that person. Some of it is going to be...I even think the diet that the person takes, and I think that those are opportunities in the future to figure out whether or not combining approaches that include diet are going to be important ones.

I think the holy grail that we’re all trying to find is a way to better identify which patient is going to respond to which medication. In the world of oncology, which is really our model, they have tests that they can do on the tissue that will help them determine which medication they're going to use in individual patients.

We aren't there yet in our world of IBD, but in my talk I highlight a few examples of things that I think are nearly ready for prime time that we could be using. One example of something that's nearly ready for prime time is to check for an HLA-DQ polymorphism that dictates whether someone is highly likely to develop antibodies to infliximab and adalimumab or not.

If I had that in my clinic today, I would probably not be starting patients that had that polymorphism on infliximab or adalimumab. I'd probably choose some of the more modern biologics or a small molecule inhibitor that won't cause antibodies.

At the very least, I would absolutely start them on thiopurine or an immunomodulator like methotrexate to prevent them from developing antibodies.

The other thing that is a pretty robust biomarker is that there is really compelling data that originally came from the laboratory of Fiona Powrie at Oxford that looks at a cytokine called oncostatin M, which is a cousin of interleukin 6. It turns out that patients that have high levels of this oncostatin M, even in blood, are those that are probably not going to respond to anti-TNF.

You could be thinking, "Well, does it tell us if they're going to respond to something else?" It doesn't, really. At the very least, it's something that guides us away from using anti-TNFs as the first line of therapy.

Then, finally, at least in some of the studies that have been done of the IL-23 inhibitors, which, as many of you in the audience knows, is one of the big advances, one of the big new categories of therapies for IBD.

In some of the studies that have been done of patients that are getting this therapy, patients that respond have high serum levels of interleukin 22 at the beginning of the treatment. That correlates with a response to therapy.

That gives us a hint of some serums cytokines, for example, that might help decide which medicine to start with. Of course, genetic markets like this HLA-DQ that I mentioned.

In the not too distant future, I think we'll be doing microbiome analyses. There are various papers that have described some microbiome species that seem to correlate with efficacy of certain medications. I think the future is always very bright for these things.

My hope is that as we keep adding to our pipeline and to the diversity of things that we're using to treat our patients with IBD, not only will we be better able to pick which medication to use in which patient, but maybe which combination of medications we could use for each patient.

Hopefully, we will get to talk about this in person sometime in the near future.