A Forward Look at IMIDs

Joel M. Gelfand, MD, MSCE; Leonard Calabrese, DO; Adam S. Cheifetz, MD; and Stephen B. Hanauer, MD, joined together in a roundtable discussion to look at the future of immune-mediated inflammatory diseases (IMIDs), including the connection between genetics and psoriasis, long COVID in the context of IMIDs, and the future of inflammatory bowel disease (IBD).

Dr Gelfand started with a discussion around genetics and psoriasis given that psoriasis is one of the most inheritable complex multigenic diseases. “In my practice, patients always want to know, ‘Why do I have psoriasis when no one in my family has psoriasis?’ or ‘What are the odds of my children having psoriasis?’” he shared. Clinicians need to be prepared to answer with accurate information. Forty percent of people with psoriasis have a positive family history, and there is roughly a 30% lifetime risk that if one parent has psoriasis their child will develop it. Dr Gelfand noted that currently in dermatology, genetic testing for psoriasis would only be done if the patient has a unique situation. Genetic testing is used with high frequency for auto-inflammatory diseases.

“The way to think of it for clinicians is how do you counsel patients to understand why they have the disease and what the odds are of their children having the disease and knowing that in select areas we may do some genetic testing to better understand the genetic phenotype of what is happening. Then where the future is going, hopefully we collect more data and understand these things more,” Dr Gelfand concluded.

Next, Dr Calabrese discussed long COVID and IMIDs. In long COVID, patients recover from the infection but either have persistent symptoms over a period of time or develop new onset symptoms during the recovery phase that persist. “At the moment, we do not have classification criteria for this. We do not have diagnostic criteria. We have some definitions that basically say this is patients who have persistent symptoms for greater than 1 month, 2 months, or 3 months that defy other explanations,” he explained. “The challenge is that we lack uniform criteria,” he added. Risk factors for long COVID include being female, having more severe symptoms with the initial infection, being older than age 40, and controversially having a mood disorder. Mitigating factors include vaccination and prompt antiviral therapy.

Dr Calabrese asked, “Shouldn’t we at this point in time be able to rigorously say that patients with IMIDs, do they have more long COVID? Do they have less long COVID? If they have long COVID, is it the same as not having an IMID or is it somehow changing it?”

Dr Gelfand answered from his experience, “As a dermatologist, if people have complications with COVID, they may be less likely to show up in my office because their skin disease is no longer their priority when they are trying to deal with the other symptoms they are being burdened with. That being said, in my clinical practice, virtually all my patients have had COVID at this point. I have only had maybe one or two who have had challenges with long COVID.”

Rheumatology has seen more long COVID because patients visit rheumatologists for pain. A large international registry has been set up to study COVID in rheumatic diseases. In the IBD world, they are seeing functional gastrointestinal disorders, with the same kind of brain-gut connections as seen in patients with irritable bowel syndrome.

Dr Calabrese ended by saying, “Like our patients who have fibromyalgia and have these complaints, validating your symptoms is the most important thing. Not arguing with them about what they have or do not have. This diagnosis [long COVID] has some stigmatization to it in certain people and just being understood and heard is a huge step and in initiating this, we use a lot of integrative medicine wellness techniques.”

Lastly, Drs Cheifetz and Hanauer reviewed the future of IBD. The treatment of IBD will be optimized and personalized by treating it smarter (predicting who will have aggressive disease), earlier, deeper (biochemical and endoscopic improvement), to target, and more effectively (proactive therapeutic drug monitoring). There are still unmet needs in IBD therapeutics, such as first-line therapies for Crohn disease, second-line therapies for ulcerative colitis, and more effective steroid-sparing agents for both conditions. In the future, precision medicine tools and stratification will play a role to deliver individualized medicine for patients with IBD and artificial intelligence and related applications will be considered. In addition, biomarkers should be incorporated into IBD clinical trial design.

“I think we can conclude by saying that the future is ahead of us,” Dr Hanauer said.

Reference

Gelfand JM, Calabrese L, Cheifetz AS, Hanauer SB. The future of IMIDs. Presented at: Interdisciplinary Autoimmune Summit; April 26–28, 2023; Virtual.