Dr Christina Ha moderated a discussion at the ACG Scientific Meeting with Dr Raymond Cross and Dr Bincy Abraham about beginning IBD therapy, changing therapeutic agents, and de-escalating or stopping some treatments.

Christina Ha, MD, is a gastroenterologist with the Inflammatory Bowel Disease Center at Cedars-Sinai in Los Angeles, California. Raymond Cross, MD, is a professor of medicine and director of the IBD Program at the University of Maryland School of Medicine in Baltimore, Maryland. Bincy Abraham, MD, is a professor of clinical medicine in the academic division of gastroenterology and hepatology at Houston Methodist – Weill Cornell in Houston, Texas.

TRANSCRIPT:

Dr Ha: Hi. I‘m Tina Ha. We just finished our session on starting, switching, and stopping treatment in IBD. I'm here with my excellent colleagues, Dr. Bincy Abraham and Dr. Ray Cross. We're just going to go over some of the take home messages from our talk. Bincy?

Dr Abraham:  Thanks Tina. I started talking about starting therapy in inflammatory bowel disease patients. I went through multiple factors that we have to look into, just the patient's disease severity, their location, if they have complications, or comorbidities.

Also take into account the factors of cost, adherence, or patient's preferences, and also their age, gender. All of those things that we take into account in providing the options for our patients so we can start them on the most ideal therapy.

Then I talked about once you start therapy, what you need to immediately monitor for. Once you do that, you really, despite whatever you start, you monitoring, you get to the point of what we want to get to as deep remission. Then if you achieve that, you're grading to continue monitoring.

If you have, you just go back to that step one again, and adjust therapy and move forward.

Dr Cross:  Thanks. My topic was switching therapy in IBD. I was set up nicely by Bincy. The key messages from my talk were in a patient who is not responding or losing response to exclude infection and make sure complications not present in a patient with Crohn's disease.

In a patient who doesn't have infection or complication, you want to confirm that active inflammation is present. That's probably the one thing to remember from the talk, and to check therapeutic drug levels to see if the dose can be optimized.

Patients with adverse events, whether you should switch depends on what type of adverse event? Is it an infection? Is it a paradoxical or an autoimmune reaction, and how severe is the infection or reaction?

The decision on what to change to depends on a number of factors. It includes the results of the therapeutic drug levels. It can include comorbid conditions. Is this a frail patient who would benefit from a safer MOA? Does a patient have extraintestinal symptoms that need to be treated with a systemic agent?

Then what about their preferences? Do they want an oral agent? Do they want a sub-q? Do they want an IV? Then of course, unfortunately, the payer is going to have a big influence on what we switch to. In the absence of any clear winner as to what to go to, there are some network meta-analyses, which can inform our decisions.

They would suggest that for Crohn's, ustekinumab, mavrilimumab may be better second line and for UC, ustekinumab and tofacitinib. Then just real quick, last point is that we do have biosimilars now. We have good data that switching to a biosimilar at least once and maybe twice is effective and safe and will no way affect how we monitor patients.

Dr Ha:  Ray and Bincy set me up for my part of the discussion, which was about stopping treatment in IBD. The first point I made is that in general, discontinuation of treatment in IBD is not really recommended because it's a lifelong condition. There is no cure for Crohn's or colitis.

The medications that got you better are oftentimes the medicines that you need to continue. However, in some circumstance, de-escalation, or adjusting the dose, potentially stopping one part of your combination therapy may be possible.

The key is that the patient has to be in a sustained deep remission, ideally with the absence of clinical symptoms and discogenic healing, biomarker normalization, not on steroids for a prolonged period of time, and then you can have the discussion.

Particularly for an anti-TNF plus immunomodulator combination therapy, using therapeutic drug monitoring, can play to your advantage because if you have room to spare, particularly with the anti-TNFs, then you can potentially stop the immunomodulator.

The key is you have to monitor therapeutic drug monitoring, clinical symptoms, biomarkers, occasional scopes at each change in therapy to make sure we don't set them back into a flare. That's the most key point is that any time you make a switch, whether or not you're escalating, deescalating, or switching, you always need to monitor your patients.

It was a great session. I really enjoyed it and learned a lot. I hope you did as well.