The Road Ahead: Optimizing the Treatment of IBD: Changing Paradigms

Moderators: Marla Dubinsky, MD David Rubin, MD

Case Discussion 1Therapeutic Limbo: How low Can We Go?

PanelistsAlan C. Moss, MD, FACG – Boston Medical CenterJean-Frederic M. Colombel, MD – Icahn School of Medicine at Mount SinaiSéverine Vermeire, MD, PhD – University hospitals LeuvenFeza H. Remzi, MD, FACS, FTSS(Hon) – NYU Langone School of MedicineAshwin N. Ananthakrishnan, MD, MPH – Massachusetts General Hospital

How do you manage de-escalation of therapy in a woman on combination therapy and planning pregnancy?• 33 yo. female on combination thiopurine and infliximab for history of perianal

penetrating and ileocecal CD wants to get pregnant but concerned about her medications and wants to be on the least amount of drugs as possible

ØMost important is deep remission at time of conception: need for evaluationØCombination therapy and risk of negative maternal or fetal outcomes ØImplications of de-escalation with stopping and impact on PK of infliximabØTiming of last infusion before deliveryØDelivery mode may be affected by status of perianal fistula

Take home points:

How do you monitor patients who want to stop biologics due to fears of side effects?• 28 yo. male with left-sided UC switched to adalimumab 10 years earlier after

developing an infusion reaction to infliximab and recent colonoscopy shows deep remission and wants to manage his disease with diet instead of biologics

ØGain a better understanding of why wants to stop medicationØImportant to have a risk benefit discussion with your patientØDiscuss role of diet in prevention of relapseØNeed to have a monitoring plan with non-invasive biomarkers ØNeed to decide on timing of repeat endoscopyØIf re-introduction of adalimumab may consider combination therapy

Take home points:

How do you manage biologics peri-operatively?• 21 yo. male with known fibrostenosing SB disease managed with infliximab and

prednsione with history of refusing surgery after pSBO admission 6 months earlier and now presents with SBO and proximal bowel dilation on MRE. Patient now agrees to surgery.

ØTiming of exposure of anti-TNF and steroids and surgery: need for delay?ØAnti-TNF therapy perioperatively and risk of post op infectionsØNon-anti-TNF biologics and their impact on post op outcomesØTiming of when to restart IBD MedicationsØIs this an anti-TNF failure and need a non anti-TNF target

Take home points:

The Road Ahead: Optimizing the Treatment of IBD: Changing Paradigms

Moderators: Marla Dubinsky, MD David Rubin, MD

Case Discussion 2Management of Enterocutaneous Fistulas

PanelistsAnita Afzali, MD, MPH, FACG – The Ohio State University Wexner Medical CenterJoel R. Rosh, MD, FACG – Goryeb Children's HospitalGary R. Lichtenstein, MD, FACG – University of PennsylvaniaAntonino Spinelli, MD, PhD – Humanitas Research Hospital

Immediate Care of Enterocutaneous Fistula• 32 yo M with ileocolonic CD w/ abscess at midline wound 4 wks post

ileocecectomy. Abscess incised w/ purulent drainage, followed by drainage of enteric contents.

Take Home Points: Ø Immediate attention to goal-directed fluid resuscitation, electrolyte

correction and critical care supportØ Intra-abdomen septic source control, broad-spectrum antibioticsØ If fistula suspected – incision for adequate drainage, skin/wound

care, pouching

Nutrition, Wound, Treatment Needs• 17 yo F with CD since age 12 with a spontaneous EC fistula with

output of 600mL/24hrs.

Take Home Points: Ø Multi-disciplinary approach (including wound/ostomy nursing team)Ø Effluent output can be caustic: need skin care, customized pouching

systems, negative-pressure wound therapyØ Categorize low- (<200) vs high-volume output (>500mL/24hr)Ø Enteral nutrition vs TPN support, bowel rest – evaluate outputØ Initiation of biologic therapy

Pre-operative Care Needs for EC Repair• 43 yo M with CD and on anti-TNF therapy & TPN support, w/ high

volume output EC fistula for 4 months. No prior surgery.

Take Home Points: Ø Generally, wait at least 6 months or longerØ Define the anatomy (CT, SBFT, endoscopy) and review best location to

enter abdomenØ Resection of fistula-containing segment with anastomosis preferred

vs suture/closure of fistula aloneØ ~20% fistula recurrence, 10-20% mortality post-operatively

Key Messages for EC Fistula Management• Multidisciplinary team is essential and includes: radiologists,

gastroenterologists, surgeons, dietitian, dedicated stoma nurse, psychosocial support• Conservative treatment: “SSNAP”• Sepsis and Skin care, nutritional support, definition of intestinal anatomy and

development of a surgical procedure

• Surgery should be delayed until both local and systemic disease controlled• Successful surgery requires the resection of the bowel associated to the

fistula• Recurrence rates remain high after surgery

The Road Ahead: Optimizing the Treatment of IBD: Changing Paradigms

Moderators: Marla Dubinsky, MD David Rubin, MD

Case Discussion III: Therapeutic Targets/End Points of Care in IBD in 2020

Panelists:David P. Hudesman, MD – NYU Langone HealthAdam S. Cheifetz, MD, FACG – Beth Israel Deaconess Medical CenterHans H. Herfarth, MD, PhD – University of North CarolinaAndrew B. Grossman, MD – Children's Hospital of PhiladelphiaWilliam J. Sandborn, MD, FACG – University of California San Diego

Case Scenarios III: Therapeutic Targets/End Points of Care in IBD in 2020: How do you assess the disease, what is your endpoint?

1. 23 yo woman with Crohn’s ileitis presents with diarrhea, abdominal pain and anemia, elevated CRP. Is treated with adalimumab with methotrexate.

2. 34 yo man with left-sided ulcerative colitis failing 5-ASA therapy and escalated to vedolizumab, now feeling ”well”. Flex sig shows Mayo 1.

3. 56 yo woman with Crohn’s ileocolitis and perianal fistula and prior ileocecectomy maintained on infliximab and azathioprine. Has diarrhea.

23 yo woman with Crohn’s ileitis presents with diarrhea, abdominal pain and anemia, elevated CRP. Is treated with prednisone, adalimumab, and concomitant PO methotrexate.• At 8 weeks of therapy, she reports resolution of diarrhea and significant improvement of pain. She has

received IV iron.

• How would you assess her disease?

• What is your endpoint of management?

Take home points:

Ø Treat to target strategy would encourage objective assessment of disease beyond symptoms. (CALM)

Ø CRP may be helpful as a target. Calprotectin is less reliable in Crohn’s of the small bowel. (UPMC study of “silent CD”)

Ø Repeat imaging is not as useful/validated for treatment titration but may impact surgical planning or clarify inflammation vs. functional.

Ø Colonoscopy has value but is not necessarily needed nor sensitive enough for full thickness inflammation.

34 yo man with left-sided ulcerative colitis failing 5-ASA therapy and escalated to vedolizumab, now feeling ”well”. Flex sig shows Mayo endoscopic score of 1. Biopsies show Geboes’ score of 3.2

• How do you reconcile feeling “well” with the endoscopic and histologic findings?•Would you change his therapy? • Is histology an endpoint of management?

Geboes Score

Grade 0 – Structural Changes

Grade 1 – Chronic InflammatoryInfiltrate

Grade 2A – Eosinophils in Lamina Propria

Grade 2B – Neutrophils in Lamina Propria

Grade 3 – Neutrophils in Epithelium

Grade 4 – Crypt Destruction

Grade 5 – Erosion or Ulceration

Nancy Index

Acute Inflammatory Infiltrate

Chronic Inflammatory Infiltrate

Ulceration

NO YES = Grade 4(Severely active disease)

NO YES Moderate or Severe = Grade 3(Moderately active disease) Mild = Grade 2 (Mildly active disease)

No or mild increase= Grade 0(no histological significant disease)

Moderately or marked increase = Grade 1 (chronic inflammatory with no acute inflammatory infiltrate)

Robarts Multiplier1 x Chronic InflammatoryInfiltrate(0-3)

2 x Neutrophils in Lamina Propria (0-3)

3 x Neutrophils in Epithelium (0-3)

5 x Erosion or Ulceration(0-3 combining 5.1 and 5.2)

Sum of the aboveTotal Range = 0-33

.Magro F, et al. Gut. 2019;68(4):594-603.

Marchal-Bressenot A, et al. Gut. 2017;66(1):43-49.

Colombel JF, et al. Gut. 2017;66(Suppl 12): 2063.

34 yo man with left-sided ulcerative colitis failing 5-ASA therapy and escalated to vedolizumab, now feeling ”well”. Flex sig shows Mayo endoscopic score of 1. Biopsies show Geboes’ score of 3.2• How do you reconcile feeling “well” with the endoscopic and histologic findings?

• Would you change his therapy?

• Is histology an endpoint of management?

Take home points:

Ø Symptoms, endoscopy and histology do not always correlate in UC.

Ø Current management goals include endoscopic improvement (healing).

Ø Histologic inflammation is associated with risk of neoplasia.

Ø Novel endpoints like “histo-endoscopic mucosal improvement” may provide additional benefit, but have not yet been validated.

Ø Practical approach includes clarifying that “feeling well” is true clinical remission and correlating with endoscopic healing.

56 yo woman with Crohn’s ileocolitis and perianal fistula and prior ileocecectomy maintained on infliximab and azathioprine. Has diarrhea.• How would you assess this patient?

• How would you assess optimization of the therapy?

• Does the lumenal bowel disease correlate to perianal disease?

• Is there a role for therapeutic monitoring?

Take home points:

Ø Careful assessment for causes of diarrhea is necessary

Ø Calprotectin may have a role given the colitis part of the disease. Is there a role for other markers? (MONITR?)

Ø Assessment of perianal disease is necessary- approach to simple assessment vs. imaging/EUA

Ø Higher infliximab levels have been associated with healing of perianal fistulas

Key Take Home Points• Modern goals of IBD management include composite assessments of

patient reported outcomes as well as disease status.• Know what markers correlate to the patient’s active disease when

they are known to be inflamed (CRP, calprotectin, imaging, others…).• Treat-to-target for high risk patients is a reasonable way to

incorporate these principles and to move management towards disease modifying endpoints.• Histological assessment of UC may have some value but is not yet an

endpoint for management.• Therapeutic drug assessment has a role in specific situations for

assessment and optimization purposes.