Approaching Ulcerative Colitis Treatment Selection


Marla Dubinsky, MD, emphasizes the role of shared decision-making and patient goals of therapy when approaching treatment selection for ulcerative colitis.

Miguel Regueiro, MD:Now we’re going to get into the treatments for ulcerative colitis [UC]. Marla, I’m going to start with you. When we think about shared decision-making and patient goals and preferences of treatment, they give us some broad strokes. How do you approach that?

Marla Dubinsky, MD:This question relates to a perfect segue from the last conversation, when we talked about the quality of life and what matters to patients. You mentioned that if you ask a patient, “What do you want to talk about today? What are your goals? Break them into short-, medium-, and long-term goals.” Even with the STRIDE-II guidance, we should divide it up and say, “This is what our initial goal is with this treatment.” Share a decision by saying, “We want you to get better.” To be honest, and the patient’s long-term goal is probably the same as the short-term goal. They’re not focused on whether their calprotectin is getting better or whether we have transmural healing. We set goals in our treatment strategies that aren’t translating when we’re having these discussions with the patient. We must be able to match the fact that we want them to get better faster, especially with ulcerative colitis. There’s an urgency that doesn’t always translate in a Crohn space when we’re talking about symptoms, so we must separate the way we’re communicating with patients with UC.

Patients tend to be most concerned about blood. Until they heal, there may be blood, so being able to translate and reframe patients into what our goals are in the short term vs where we’re going to get to is the most important thing. When you ask patients what they’re most concerned about, it’s safety, particularly malignancy. You must face that head-on, knowing that whatever you’re going to communicate, you must see it through the lens of safety and convenience. They know that these drugs work—they got approved—but they don’t know how much they work. They don’t know what the P value was, the delta from placebo; that doesn’t matter. They know that this drug is approved. They may have seen a commercial, which may be frightening. Being able to understand what your needs are, how we’re going to take that step to get you there, what our goals are, and why we want to achieve those goals so you have a durable, sustained response and aren’t going from flare to fine, flare to fine. How do we flatline those curves that patients are used to while explaining the safety of these therapies? Why will the risk of the disease itself always outweigh the risk of our therapies? That’s the way I approach my patients every day when I’m making treatment decisions with them.

Miguel Regueiro, MD:In this shared decision approach, we ask the patient what their goals are, what they want out of the visit, and then define the goals that we see. You already mentioned some patient-reported outcomes in ulcerative colitis. Bleeding is a big 1, and diarrhea as well. Then we come up with a sustained plan to keep them in remission.

Dave, I want to move to some of the guidelines. There’s a lot of discussion around guidelines from the ACG [American College of Gastroenterology] and the AGA [American Gastroenterology Association], and many societies have issued guidelines. What are your thoughts on the adoption and utilization of guidelines in community practices?

David P. Hudesman, MD: The guidelines are important. It’s a nice road map for what you should be thinking about, but a lot of what goes into the guidelines are the data we have. If we’re talking about choosing therapies, we don’t have the ideal head-to-head trials. We have 1 head-to-head trial in ulcerative colitis and 1 head-to-head trial in Crohn. It’s limited. The guidelines give you a nice menu of options to choose from, but there are no specific details on whether you should start with this therapy or that therapy. The overall concept on how we should grade severity of disease—there’s a nice updated index from the American College of Gastroenterology—is that we should think about not only symptoms but also biomarkers, fecal calprotectin, endoscopy scores. How we monitor these patients thoroughly is really important. Then again, it’s a road map. Having that discussion with patients is how you make those decisions.

Miguel Regueiro, MD:I agree. The guidelines are important, but they sometimes fall short in reality. I dare say that the 4 of us probably don’t look at the guidelines specifically on a patient. I imagine that’s even less common in the community.

Transcript Edited for Clarity

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