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Expert Perspectives on Updates in the Management of Ulcerative Colitis - Episode 9

Treatment Guidelines and Goals in the Management of Ulcerative Colitis

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Maia Kayal, MD, explains how treatment guidelines can be used to direct and standardize treatment approaches in patients with ulcerative colitis.

Maia Kayal, MD: Treatment guidelines published by the American Gastroenterological Association and the American College of Gastroenterology play a significant role in our treatment decisions. First, they help to standardize treatment across patient populations. Second, they provide the most up-to-date guidelines on how we should approach patients with mild, moderate, or severe ulcerative colitis. When I first meet a patient, I typically go through the guidelines with them so they understand our approach to therapy and our reason for optimization or escalation to biologic therapy when needed.

Goals of therapy for patients with moderate to severe ulcerative colitis have been published by the International Organization for the Study of Inflammatory Bowel Disease in the STRIDE-II guidelines that were updated in 2021. The treatment targets for patients with moderate to severe ulcerative colitis include a reduction in stool frequency, a reduction in rectal bleeding, normalization of endoscopy, in addition to normalization of fecal calprotectin. Long-term targets include a resolution of disability and a normalization of health-related quality of life. When we start therapy for patients with moderate to severe ulcerative colitis, we always start the conversation by saying what our treatment goals are. It’s important for patients to know what we’re working toward so that as a team we can achieve that treatment goal.

David P. Hudesman, MD: Our goals of therapy are to put somebody into clinical remission, meaning they’re feeling great, their quality of life is significantly improved, if not great. We also want to heal them on the inside. This is endoscopic remission, meaning we do a colonoscopy and everything looks great on the inside. Once somebody is in remission, and most of this comes from our Crohn disease data, but we can’t just stop therapy. There have been a couple of trials now, the original trial was called STORI, and more recently a nice randomized study called SPARE. These were looking at patients on an anti-TNF [anti–tumor necrosis factor therapy], and an immune modulator, in remission, feeling great. Then when they stopped the anti-TNF or they stopped the biologic, within 1 to 1.5 years, about 50% of patients flared. We don’t want to withdraw therapy once we get somebody into remission. However, we may be able to deescalate. If somebody is on a combination of both a biologic and immune modulator, or in some situations 2 biologics, maybe we could pull back on the immune modulator and continue the biologic like the anti-TNF.

The other important part of caring for somebody when they’re in remission is disease monitoring, and closely monitoring these patients. Where we miss the boat is a lot of times somebody is feeling great, you do a colonoscopy and it looks great on the inside, and then the patient isn’t following up or we’re not following up with that patient, and the next time we see them is when they’re flaring. Monitoring them with blood work, CRP [C-reactive protein], a stool biomarker or fecal calprotectin every 3 to 6 months when somebody is well is critically important. The last thing is once you have ulcerative colitis for more than 8 years, so from symptom onset to present of more than 8 years, and somebody with more than their rectum involved, they have an increased risk of dysplasia, and we need to do surveillance colonoscopies as well for monitoring.

Treatment guidelines give us the roadmap on how to care for our patients, but really what goes into these treatment guidelines are large-scale randomized controlled trials that got a lot of these therapies FDA approved. There were some interesting studies looking at how many patients that you’re seeing in the office would qualify for these clinical trials, and it was less than 50%. Clinical trials give us the roadmap, but we really need to tailor our therapy for that specific patient. The way we do that is our experience plus what the real-world data show. There are a lot of nice real-world data using many of our agents in different settings. Also, real-world data help with maybe not only picking what therapy should go first, but in our patients who come to our office who failed 1 or 2 therapies, what happens next? Guidelines give us the roadmap, and we need real-world evidence plus our clinical experience to tailor those guidelines.

Transcript Edited for Clarity