Treatment Factors of IBD


Experts discuss treatment options for patients with Inflammatory Bowel Disease (IBD) and clinical factors to consider.


David Hudesman, MD: Miguel, before we get into the specifics of the therapies, when you’re talking to patients, what factors do you consider when deciding on the right therapy, and if it’s a biologic or a small molecule?

Miguel Regueiro, MD: There are multiple patient-centered factors. What’s the age of the patients? Do they travel a lot? Do they want a pill or an injection? Do they want an infusion? [Also, we consider] safety of the medicine and how quickly it works. Patient-related factors include, do they have extraintestinal manifestations? Is it small bowel? Is it colonic Crohn [disease]? Do they have other factors where they’re concerned about the safety risk? Do they have repeated infections? We’d need to consider different therapies. Some of these are listening to patients and meeting the expectation they have. When we have oral small molecules, injectable biologics, and infusible biologics, we have some great options and can fit the patient’s needs and profile.

David Hudesman, MD: Millie, if you could, expand on that a little further. In your practice, what do those discussions look like with the patients?

Millie Long, MD, MPH: It’s amazing that we’re having these discussions, that we have numerous options. It can become confusing. What do you use first? What do you use second? How do you approach this? We’ll go into all that, but the most important piece is that shared decision with the patient. We need to understand their perspective. Are they prioritizing safety? Are they prioritizing avoiding prednisone so that they can have a drug that acts quickly? How is that relationship with them? Do they want something that doesn’t require as much testing? You must get at what the patient’s goals are and help them move toward that decision. Even though we have these wonderful novel therapies, TNF [tumor necrosis factor] agents are still there. We have a lot of experience with TNFs. They’re very effective drugs, and they’re part of every discussion in terms of what can be used for an individual patient.

David Hudesman, MD: When I’m approaching patients, obviously, the drug needs to work, the therapy needs to work, right?

Millie Long, MD, MPH: Yes.

Anita Afzali, MD: Right.

David Hudesman, MD: Efficacy is definitely No. 1. Then we can talk about it, but from a patient perspective, they’re not usually thinking that way. Maia, in your experience, what are patients usually thinking about when they’re starting these therapies?

Maia Kayal, MD: That’s a great question. It informs most of our conversation early on. A lot of my patients are thinking, “What therapy is going to get me back to my best quality of life as fast as possible?” When we see patients, they’re often quite debilitated and very ill, and it’s taking a significant toll on their lives. College students can’t make their classes, moms and dads aren’t able to manage their kids, individuals aren’t going to work. The No. 1 thing on their mind is, “When can I get back to the best quality of life, to my baseline? When can I get relieved of this disability and this debilitating disease?” That’s the first question I get: how fast can you get me back to where I was before? Efficacy is very important, but safety plays a big role as well. Many patients want to talk about how their therapy is going to impact their day-to-day. If it’s something like an oral molecule, that’s great. It’s not having too much of an impact. But when you start to talk about infusions and injections, that needs advanced planning, and patients need to be able to incorporate that into their daily life. Much of our conversation is based on how fast I can get you back to your baseline and what the impact of the therapy is going to be on your day-to-day life.

David Hudesman, MD: I agree. Patients are focused on that, and safety is always there. They want to get better. Once they’re better, do they need to continue? What are the safety concerns?

Millie Long, MD, MPH: We’re on the same page about this: the safest drug is the most effective drug.

David Hudesman, MD: Exactly.

Millie Long, MD, MPH: The complications of the disease that are the most concerning.When we have that conversation, we say, “That’s what our goal is.” Yes, we want to do it in the safest fashion possible, but if the most efficacious drug may not be the safest on paper, that still might be the safest for that patient [in order to] avoid the disease complications.

David Hudesman, MD: That’s a great point. It goes back to that shared decision-making. You’re going to have to build that relationship because we have those conversations and maybe if it’s the first therapy the patient’s on, they don’t always necessarily get it, right?

Millie Long, MD, MPH: Right.

David Hudesman, MD: Maybe it’s a second therapy, and they need another course of steroids. Or they felt great for 6 or 9 months, and that’s it. That’s when that starts to happen. Another part of that is the durability, which I’m going to talk about. It’s not just about feeling great a few weeks or a few months later. What about 1, 3, or 5 years later.

Transcript edited for clarity.

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