Advice for community physicians and gastroenterologists to help manage patients with ulcerative colitis.
Andres Yarur, MD: There are several important things that we usually advise gastroenterologists to do when treating patients with ulcerative colitis [UC]. We have several options to treat moderate to severe ulcerative colitis. But it’s also important to mention that we need to approach treatment in a better fashion with the drugs we already have. For example, we know that we should aim to treat earlier, with more efficacious therapies, and not wait until someone has a complication to introduce a biologic or a new-generation small molecule. For example, a patient on mesalamine who’s symptomatic and requires multiple courses of steroids should likely be started on another drug. Another important piece of advice is to remember that we’ll have newer therapies in the future. It’s important to discuss these other options with the patient, because it’s a combined or shared decision with the patient about the best option for them. Some patients may be uncomfortable getting injections or infusions, and they’d prefer an oral therapy. Also, some patients may feel uncomfortable with the potential adverse events.
Maria T. Abreu, MD: The advice I would give a gastroenterologist is not to be afraid of our new-generation therapies—to treat our patients with ulcerative colitis—when it’s clear that mesalamine isn’t controlling their symptoms. Also, be aware of patients who are steroid dependent. Too often you see a patient who can’t get below 15 mg of prednisone. They come in, their faces are round, they’ve gained weight, and they have horrible acne. There’s damage that has been done that’s undoable. Patients scare themselves by reading things on the internet. When they approach the doctor and say, “I’d rather be on steroids because I know the risks of steroids,” as gastroenterologists, we need to speak with confidence that steroids are the “bad guys” and other medications that we’ve been talking about are safer than steroids, both short term and long term. Therefore, we need to speak with confidence and not wait years for these people to be melted away by steroids before we do something about it.
Timothy Ritter, MD: The treatment of UC is a dialogue between you and the patients. The best advice I could give is that you need to sit down with the patient early on in their disease and define targets and goals so the patient is onboard with treatment of the disease. Once you define the targets, you treat to the target and reassess. OK isn’t good enough. You need to get these patients into remission. Once in remission, it’s important to consistently monitor these patients, whether it’s fecal calprotectin, periodic endoscopy, or whatever you and the patient agree on. It’s important to continually monitor these patients to keep them in remission and to keep the inflammatory burden down to improve their symptoms, their quality of life, and hopefully to decrease the risk of complications progressing. It’s a matter of persistence and using the right medication at the right time.
It’s also important to not undertreat patients. There’s a trend among a lot of folks to start patients on mesalamine so they get a little better, but that’s good enough. Until you’ve assessed their inflammation, endoscopy, and histology, you need to consider moving forward if you’re not meeting the targets that you set.
Andres Yarur, MD: In general, how we approach the treatment of ulcerative colitis has dramatically changed. We should not classify patients as mild to moderate or moderate to severe. Many patients, now classified as mild to moderate, need newer therapies, or as gastroenterologists, we should approach these patients differently. It’s important to mention that there are several new drugs coming in the next year or 2, and it’s important to be updated on the benefits and risks of each drug.
Maria T. Abreu, MD: As far as I’m concerned, the way the future is looking for people with IBD [inflammatory bowel disease] is using most of the medications we have in rational combinations. These combinations of medications will complement one another. Obviously, the reason it’s a bit pie-in-the-sky is because of finances. Because we use biosimilars and, presumably, some of the medications we have in clinical trials, the only way we’re going to have a higher response rate and remission rate, especially in the more difficult patients, will be by using combination therapies.
Timothy Ritter, MD: Thank you for allowing me to participate. It was a pleasure to be at DDW [Digestive Disease Week] this year. It was very exciting. Every year, as we go to these conferences, the information gets better and better.
We’re constantly learning about new mechanisms, how to properly use these medications—in the right patients—and how to assess patients and get them a better quality of life and long-term remission. It’s a very exciting time to be practicing medicine.
Transcript Edited for Clarity