Professor Axel Dignass, president of United European Gastroenterology, discusses the current state-of-play for the treatment and care of inflammatory bowel disease (IBD), highlighting the key developments and routes to achieving successful patient outcomes.
Inflammatory bowel diseases, or IBD, are chronic disorders of the gut and include Crohn’s disease (CD) and ulcerative colitis (UC). The primary symptoms of IBD include abdominal pain, cramping, diarrhoea, urgency, weight loss, rectal bleeding and fatigue. In addition to these main symptoms, around 25–40% of IBD patients may experience other more non-specific symptoms in the eyes, joints, bones, skin, kidney and liver as well as conditions like anaemia. The causes of IBD are still unknown; however, it is thought that a genetic predisposition and environmental factors impact the likelihood of being diagnosed with IBD.
The prevalence of IBD is increasing worldwide.1 In Europe it is estimated that between 2.5–3 million people have IBD.2 IBD has also started impacting a much younger population and there has been a rise in the number of children being diagnosed, with up to 20% of cases developing in childhood.2 In Europe that equates to over half a million children. This general rise is particularly prominent in urbanised and developed countries, which has largely been attributed to a westernised lifestyle as well as a number of associated environmental factors.1
There is currently no known cure for IBD and treatment is aimed at minimising the impact of the condition and achieving symptomatic long-term remission. The effectiveness of treatments vary from case to case as there is no one treatment that works for all patients. Increased knowledge of IBD has resulted in the development of new treatments, medications and approaches. For example, there is a growing importance attributed to mucosal healing, particularly in paediatric patients where the enhancement of growth and bone formation is so key.
More advanced biological treatments, such as anti-TNF antibodies, anti-IL12/IL23 antibodies and anti-integrin antibodies, have been sought to help with this process. Other new and promising medications are also being developed, including various anti-IL23 antibodies, new anti-adhesion molecules, JAK inhibitors and SP1-receptor inhibitors, to improve patient experiences and outcomes.
Moreover, our growing understanding of nutritional therapy and identification of predictors of response to medications are allowing for increasingly personalised treatment plans.
Alongside these clinical developments, a number of approaches to make IBD treatment more all-inclusive have been central to securing more positive patient outcomes.
Treat-to-target in IBD
The ‘treat-to-target’ or T2T management approach has been deployed to assist with underlying inflammation, minimise how active the disease is during the early stages of IBD, act as a preventative measure for disease progression and help to improve the long-term outcomes for the patient. It also aims to reduce the risk of complications such as the development of strictures, fistula, functional impairment, or dysplasia.
T2T management requires a collaborative approach from both the clinician and the patient. The process involves identifying an appropriate target, selecting initial treatment according to the risk of disease progression, measuring the general characteristics of the disease, monitoring progress (tight control), and optimising therapy and care to achieve positive clinical outcomes.
A key part of T2T is consultation with the patient to fully understand their specific needs. This involves setting predefined treatment targets with the patient, initiating appropriate and early treatment according to the risk of disease progression (early intervention), continuously monitoring disease activity (tight control), and modifying treatments until the original targets have been met. This engagement with the patient is particularly important amongst paediatric patients where non-compliance with the recommended treatment plan is common.
Multidisciplinary teams
As with all IBD treatments, to achieve optimal patient outcomes from the T2T approach it is paramount that the patient is monitored by a multidisciplinary team. This team should comprise clinicians, advanced practice providers, nurses, allied health professionals (AHPs), psychologists and dieticians among other HCPs. Once established, a multidisciplinary team should meet regularly to discuss the management of an IBD patient and ensure support is coordinated correctly.
A multidisciplinary team is critical to outcomes as the needs of IBD patients, particularly paediatric patients, are often both complex and highly individual, requiring a personalised treatment plan. Over and above the physical implications of IBD, the indirect and invisible costs of the condition are significant and should form an integral part of the treatment plan.
Multiple studies have demonstrated that the burden of IBD can negatively impact education, work and social life, both as a result of the psychological impacts as well as through forced absences caused by events such as flare-ups and treatments.1,3,4,5
Such an integrated and coordinated approach to care for IBD patients may prove challenging to healthcare systems, particularly with the prevalence of IBD on the rise. It is however a necessary step in securing optimal, effective and cost-efficient care for IBD patients moving forward.
Patient-reported outcomes for IBD
Another increasingly important consideration in the treatment and care of IBD patients is patient-reported outcomes (PROs), which reflect a wider trend to place the patient at the centre of condition management. PROs incorporate outcomes and experiences that may not necessarily be obvious to the clinician but are very important to a patient, and imperative to their treatment plan and management.
Thus, it is not surprising that the attitudes of patients and physicians about disease burden, treatment targets and treatment options vary significantly. In relation to IBD specifically, only the patient will be aware whether or not they are feeling fatigue and pain, or whether they have blood in their stools. Yet as primary symptoms of IBD and flare-ups, these PROs form a central part of the treatment process.
To maximise patient outcomes across Europe there is a need to continue improvements in the treatment and care of IBD patients. This will help to ensure that sustainable, efficient and cost-effective services are delivered into the future to those who need it most. However, we also need to be mindful that many countries do not have the resources or capacity to deliver optimal levels of treatment, and this must change if we are to truly maximise outcomes in IBD patients.
Author
Axel Dignass MD PhD
President of UEG and director, department of Medicine, Agaplesion Markus Hospital, Goethe–University Frankfurt am Main, Germany
References
- M’Koma AE. Inflammatory Bowel Disease: An Expanding Global Health Problem, Clin Med Insights Gastroenterol 2013;6:33–47.
- Burisch J et al, on behalf of ECCO-EpiCom. The burden of inflammatory bowel disease in Europe. J Crohns Colitis 2013;7(4)322–37.
- Ruggeri M et al. Economic burden of IBD in Italy. Digest Liver Dis J 2018;50(2).
- Kuenzig M et al. The Impact of Inflammatory Bowel Disease in Canada 2018: Indirect Costs of IBD Care. J Can Assoc Gastrenterol 2019;2(Supplement_1, 2):S34–S41.
- Wilson B et al. A European Crohn’s and ulcerative colitis patient life IMPACT survey, ECCO. www.ecco-ibd.eu/publications/congress-abstract-s/abstracts-2012/item/p406-a-euro.html.
