Managing Inflammatory Bowel Diseases in the Community



Miguel Regueiro, MD: Jessica, I'm going to have you give us some of your take-home tips for the community. Then for Marla, Bill, and David, some lasting impressions that you have or any topics that you'd want to address. Jessica, what are you telling your community GI [gastroenterologist] about IBD [inflammatory bowel disease]?

Jessica R. Allegretti, MD, MPH: Putting together everything we've been discussing today, when I'm talking to my community colleagues, it’s about going back to basics and confirming the diagnosis when you have a patient in front of you. Using a multimodal approach to understand your patient's risk factors, how sick your patient is, and if they are at risk for bad outcomes to try to get them on the appropriate therapy up front. I stress that we're not doing this everyone-gets-mesalamine-up-front model anymore and try to use personalized risk factors and risk assessments to get patients on appropriate therapy up front. Thinking through patient's individual risk factors, their comorbidities, and using those together to get the patient on the right therapy. Stressing this treat-to-target model, that when you are starting a therapy, you have to have goals set for both you and the patients that you need to be meeting, and if you're not, then you need to understand why you're not meeting those and make changes so that you are. That's something I often talk about with my community colleagues.

Thinking through a lot of what David was just discussing as well, how are you going to get the therapy? Thinking through all the factors, whether it's determining the mode of administration, getting your insurance companies on board, and thinking through those processes. I know we're very fortunate. At tertiary care centers, we have a lot of support to do some of these things, and some of our community colleagues don't necessarily have that. Up front, we need to be thinking through what the processes are for infusion centers, for getting injectables, and what specialty pharmacies are you working with? Familiarizing yourself with those processes up front will save a lot of time once you're in the thick of it with patients.

Then always, if you're feeling overwhelmed or unsure, feel free to reach out and refer to your colleagues at tertiary care centers who are happy to co-manage patient cases with you and provide advice. We fully recognize that this field is getting increasingly more complicated. We have a lot more choices, which we're happy about, but we understand that if you're not doing just solely IBD care, it can feel a bit overwhelming. Utilize us and our colleagues as resources to help provide the best patient care possible.

Miguel Regueiro, MD: Dr Allegretti, thank you for that wonderful overview. That summarized everything that we had talked about. Then I want to thank again all of you for your information. Before we conclude, I want to get some final take-home thoughts from each of you. Bill, your take-home thoughts?

William J. Sandborn, MD: This is an exciting time for patients. As Jessica just said, it can be a little daunting for practitioners, but it's also an exciting time for practitioners. We have a lot of therapeutic choices now, and over the next few years, we're going to have a lot more. The evolution of use of biomarkers in clinical practice is a big deal, evolving thinking about treating to target. We didn't talk much today about precision medicine in the sense of picking drugs based on biology, but that's going to come to the forefront in the next 5 years as well. Then, telemedicine and team care are huge issues. We probably won't recognize, for the better, what IBD care will look like in the 5-to-10-year time horizon. It's going to be so much better as all this comes together. It's a gratifying and exciting time to be taking care of these patients.

Miguel Regueiro, MD: I agree. To pick up on your points about telemedicine and virtual care, we'll bundle all of the biomarkers, the treatment, the outcomes. The virtual care, and the telemedicine care probably will also evolve into e-consults, as I think many of us are starting to do, and even e-second-opinions with our physicians across the country. Jessica, you mentioned bringing groups together from remote areas. That's probably going to be in the next 2 years. Before all of this, I would have said 10 years, but we're going to be closer.

William J. Sandborn, MD: I'm smiling, because I just saw a patient that you did an e-consult on, and he came back and said, “They didn't tell me anything that you didn't already tell me, so we're good to go.”

Miguel Regueiro, MD: He came to Cleveland Clinic, and I looked at him, “Who took care of you before?” “Bill Sandborn.” “OK, I’m not sure there's going to be much there.” Dr Dubinsky, what are your take-home points?

Marla C. Dubinsky, MD: As Bill alluded to and as I noted before, although it can be daunting, with advances in technology and our ability to integrate genetics and biology into our practice, there's a rapid increase in technology and platforms that could help to bring precision medicine into the clinic for all patients, no matter where you're seeing them or where you're diagnosed: what city, what state. The fact that there has been a clear understanding on the role of team and tech, as Bill was noting as well, we're going to get better at how we deliver care, and that means that, not only are treatments expanding, but the way we deliver care is going to improve as well. It's a win-win for patients and for every stakeholder: those who seek care, deliver it, and pay for it. Everyone is going to benefit from these advances in the field of IBD.

Miguel Regueiro, MD: Great. Thank you, Marla. Then, David, I'll turn it to you to give the final word.

David T. Rubin, MD: What we've heard today is a variety of concepts that have emerged in our management of IBD. My colleagues have said it very well, so I don't want to repeat all of that, except to say that we are in an era of disease modification now in IBD, where we need to be focused not just on effective therapy in the short term, but on changing outcomes in the longer term as well. Every patient with IBD deserves a team approach to their management and a proactive assessment and plan. I'm looking forward to that, and I'm sure that our patients will benefit from it.

Miguel Regueiro, MD: The team approach, as probably all of you are doing too in the virtual world, has become somewhat easier and different, either as disconnected visits for the patient over the period of a week or 2, as they sometimes like little breaks between rather than all at once, or sequential visits, or in the same room visits. It’s an interesting time.

With that, I wanted to conclude today, and I wanted to thank my colleagues: Dr Allegretti, Dr Dubinsky, Dr Sandborn, and Dr Rubin. To our viewing audience, we hope you found this HCPLive® Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity

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