Disclaimer

This podcast is for US healthcare professionals only and is intended to be listened to as it was originally produced by Pfizer. This podcast has been funded by Pfizer, and the participants have been compensated by Pfizer for their time. The healthcare professionals featured are sharing their own opinions based on their clinical experiences. This promotional activity is not certified for continuing medical education. 

Narrator

Welcome to the latest episode in our podcast series, IBD TalkTract, sponsored by Pfizer, designed to engage healthcare leaders in conversations about inflammatory bowel disease (IBD) care management opportunities. Our podcasts feature IBD specialists involved in care innovation at their institutions. Be sure to check out our first episode, which is about the integration of clinical pharmacists into IBD care. 

Along with advancements in the development of therapies, several innovations in IBD care have shown the potential to improve care along the patient journey. Two strategies in particular—risk stratification and treat-to-target—may be effective in the early identification and successful long-term management of IBD.^1-3 Risk stratification is needed to select an appropriate first-line therapy,⁴ and treat-to-target specifies short-, intermediate-, and long-term treatment goals, documenting specific treatment targets to be achieved at each timepoint.³

On today’s episode, we’re joined by 2 experts who will give us an inside look into how they are using risk stratification and treat-to-target at their institutions to improve IBD care along the patient journey. 

Let’s meet our guests. Today, we have 2 leading gastroenterologists, Dr Aline Charabaty, clinical director of an inflammatory bowel disease center; and Dr Edward Barnes, a gastroenterologist and clinical investigator, as well as a co-director of a multidisciplinary inflammatory bowel disease center.  

Welcome to the podcast. 

Aline Charabaty 

Thank you for having me. 

Edward Barnes 

Thank you. I’m looking forward to our discussion!

Narrator

Dr Charabaty, let’s begin with you. Before we get into risk stratification and treat-to-target today, let’s start with the extended care team at your institution. In your experience, why is a multidisciplinary team important? 

Aline Charabaty 

So here at our institution, we’ve found that in order to provide comprehensive care to people living with IBD, we really need a multidisciplinary care team of clinicians who can support the patient at every point in their journey. That is because IBD is a complex disease. It’s often a progressive disease that affects a patient’s health and life at so many levels. 

And I want to note that you don’t have to be a large institution to implement a multidisciplinary approach. At a smaller practice, your core IBD team might include a physician, an IBD nurse, and a pathologist. And then you collaborate with a colorectal surgeon and other medical specialists outside the practice and that can expand the team’s expertise and efficiency. And of course, this will help ensure that patients with IBD have the comprehensive care they need and deserve. 

Narrator

You bring up an interesting point about scalability. Dr Barnes, how can other institutions, whether large or small, effectively scale their teams or programs? And what are some of the main considerations or key steps? 

Edward Barnes 

The thing with scaling is that it may require an upfront investment from your care team. But ultimately, these practices will improve patient care and help lower costs in the long run.  

In terms of things to consider, the first step is to add key team members who will help you be efficient. This will allow the IBD specialist to increase the number of patients seen and the number of advanced therapies administered. Having a well-functioning care team also allows more care to take place outside of a traditional IBD center of excellence. And that’s important given the increasing prevalence of IBD.⁵

Narrator

Dr Charabaty, as you mentioned, IBD is progressive and affects health and life at many levels, but fortunately, as Dr Barnes mentioned, we now have advanced therapies that help our care teams improve outcomes for these patients. What key factors do you look for before considering advanced therapy for your patient populations, and what is a key challenge that clinicians could experience? 

Aline Charabaty 

Well, the first thing to consider is what type of therapy is appropriate for a specific patient. The American College of Gastroenterology, or ACG, and the American Gastroenterological Association, or AGA, have guidelines that include a range of medications to help physicians identify treatment options that best fit a patient’s individual needs. 

Now, there are so many different treatment options available, it can really make any physician feel overwhelmed as to which one to prescribe. So, to help us decide, we look at a variety of factors, including disease location and severity, disease phenotype, comorbidities, prior treatment response, pregnancy planning, and of course patient preference. And, it’s important to remember that we need to consider access from insurance coverage to how a therapy is given. 

Narrator

And how about you, Dr Barnes, how do you decide when to consider a patient for advanced therapy options, and what is a key challenge from your perspective? 

Edward Barnes 

I’ll start with the second question about the key challenge because the biggest challenge is getting patients on appropriate therapy early enough in their disease course. In my experience, unnecessary delays may lead to significantly worse outcomes. 

As for deciding on when to use advanced therapies, I consider disease activity and the patient’s disease severity. At my institution, a lot of our work is focused on the early identification of patients at risk for a complicated disease course. These patients may benefit the most from being prescribed an advanced therapy. 

Narrator

Thank you both for sharing your experiences and insights on choosing advanced therapy options and the challenges that may arise. Now, let’s turn to the strategies utilized to manage patients with IBD, focusing on risk stratification and treat-to-target as ways to combat the challenges you’ve mentioned. Let’s start with you, Dr Charabaty. How have you incorporated treat-to-target strategies into your institution’s care model, and what was the motivation to do so? 

Aline Charabaty 

Our motivation, and our goals, are to improve patient outcomes by achieving and maintaining steroid free remission, restoring and preventing disease-associated disability.  

In our practice, as part of the treat-to-target strategy, we monitor biomarkers very closely. We know that achieving biomarker and endoscopic remission decreases the risk of flares, hospitalization, steroid use, disease complication and progression, and the need for surgery. 

So, we ordered labs that include inflammatory markers at regular intervals. So typically for me, at first I ordered these labs a few weeks after starting a new therapy and then at the end of the induction phase, and then periodically thereafter. This really helps us monitor treatment response and adjust the treatment as needed. 

I typically also do a colonoscopy 9 to 12 months after starting or adjusting a therapy to document mucosal improvement. 

Now, as we clinicians are aiming for objective measures of remission in our treat-to-target strategy, patients are primarily thinking about symptoms resolution as a measure of treatment success. So we always have to bring it back to the patient and keep it at the center of what we are doing and really ask them about their treatment goals. And from there, we need to take the time to explain to patients how our treat-to-target objective goals align with their own goals of care. 

Narrator 

That partnership between patient and provider is so important. Dr Barnes, how have you incorporated risk-stratification strategies into your institution’s care model? 

Edward Barnes 

So, risk stratification is a hot topic in the field of IBD, and at my institution, risk stratification is important as an objective, evidence-based way to predict disease progression. A classic way that we think about it is during postoperative management of a patient with Crohn’s disease. We use risk stratification to prevent recurrence by looking at different clinical and other factors to determine when to start advanced therapies. 

And there are also clinical decision support tools that can help guide therapy decisions that are being utilized more in practice and are supported by some professional organizations. 

And lastly, looking ahead, the work that’s being done with blood-based biomarkers for risk stratification may have great potential. But we need to see more evidence for that compared to other models. 

Narrator

Clearly, there are benefits to these strategies, so let’s talk about how to get there. Dr Charabaty, can you share your experience with risk stratification and outline the steps needed to implement it? 

Aline Charabaty 

This is such an important topic, and the way I think of it is I look at 3 factors to help me with stratifying risk in a patient.  

One is disease-specific risk. So, I look at the patient’s age at diagnosis, the disease extent and severity, and the disease phenotype. Is there a history of surgery or other complications? And did the disease respond to therapies in the past, or is it a disease that’s more difficult to control? 

Second, I look at patient specific factors. How fit or frail is the patient? Do they have comorbidities that can put them at higher risk of certain medication side effects?  

And finally, based on all these factors, I look at the patient’s risk of disease progression. What I mean by that is, if we under treat the disease because we did not start the right therapy, what is the risk of the disease progressing and leading to complications and disability? And what can we do to prevent that? 

Narrator 

That’s a really comprehensive way to approach risk stratification. Dr Barnes, can you share your institution’s motivation for implementing treat-to-target strategies and the benefits you’re seeing. 

Edward Barnes  

Sure. Over the past decade, treat-to-target has grown in terms of both our evidence and the ability to implement it. For example, recommendations from various studies have enabled us to adopt treat-to-target strategies in clinical practice. So that’s a great motivation. 

The benefit we’re seeing is having some patients in remission earlier, as well as some patients in sustained remission. These are our goals in taking care of patients with IBD. 

These positive benefits are possible because we’ve been able to implement workflows to initiate advanced therapies early and monitor response using noninvasive testing and other objective assessments, like colonoscopy, to gauge response.  

We’ve also built dashboards to monitor our practice patterns and see how well we’re doing with treat-to-target and how well we’re doing with avoiding non-value practices like keeping patients off steroids and out of the hospital. 

Narrator  

Those are great benefits! So, Dr Barnes, you’ve talked about treat-to-target at your institution. Can you share your approach to risk stratification and what you see in the future for other strategies that guide treatment decisions? 

Edward Barnes 

Absolutely. So there are some areas where risk stratification is well-defined, like we talked about in postoperative Crohn’s disease. But there are areas where the evidence base for risk stratification in IBD needs to be more robust, so we’re waiting to see where the research takes us in the future. 

In terms of those future strategies to guide treatment decisions, we live in a multi-omic world with rapidly advancing technology. Just look at companion diagnostics. We don’t have companion diagnostic tests that we use regularly for patients with IBD. But these tests have revolutionized care for cancer patients. I think we can aspire to a similar revolution in IBD. 

Narrator 

That’s an exciting prospect for IBD patients! Based on where we are today, what role do members of the IBD care team play in making treat-to-target strategies successful? 

Edward Barnes 

A multidisciplinary IBD care team makes a huge difference in making these strategies more effective and certainly more efficient. For example, if you want to standardize objective assessments, nursing staff can set up standing lab orders and regular check-ins, ensuring they are happening in a timely manner. This facilitates starting patients on advanced therapies in a treat-to-target strategy. 

In addition, at my institution, our clinical pharmacist is one of the most valuable members of our team. When we start patients on an advanced therapy, there’s a short turnaround to see our clinical pharmacist, who will ensure they get appropriate assessments. That leads to a seamless transition to the first follow-up with the IBD specialist, who can then evaluate the patient’s clinical status and determine the next steps.   

Narrator 

It’s great to see the nursing staff and clinical pharmacists bringing their expertise to IBD care teams. Tell me, how do clinical guidelines, such as those from the ACG or AGA, influence strategies within your institution? Are they utilized to support the implementation of treat-to-target strategies? Let’s start with you, Dr Charabaty. 

Aline Charabaty 

There are several recommendations from the GI organizations that inform our treat-to-target strategies. The first one, and I think is one of the most important ones, is that we need to treat early with an effective therapy and avoid multiple cycles of steroids before starting these advanced therapies. 

The second, as I’ve mentioned, is choosing what type of therapy is appropriate for a specific patient. And this can be difficult with all the available options that we have now. The AGA recently published a paper that has been extremely helpful for clinicians. It positions therapies in IBD by ranking medications from high to intermediate to low efficacy based on whether the patient was previously exposed to anti-TNF or is bio-naïve. 

And finally, both AGA and ACG recommend using objective markers of remission such as inflammatory biomarkers, colonoscopy, small bowel MRI—rather than relying on symptoms alone—to assess treatment response and disease remission. 

Narrator 

What about you, Dr Barnes? How are guidelines utilized at your institution? 

Edward Barnes 

We lean heavily on guidelines and consensus statements, and I definitely encourage following guidelines. They help us craft practice patterns that are effective for most patients we see in practice.  

Take risk stratification, for instance—the ACG models for disease prognosis in ulcerative colitis (UC) actually shifted our thinking to assessing a patient’s prognosis and determining how to risk-stratify them. And that’s huge! 

And for both UC and Crohn’s disease, the biomarker guidelines helped identify a mismatch of patient symptoms versus the objective information that something like fecal calprotectin provides. It has helped to inform our thinking and the way in which we use objective information to monitor the patient. This, in turn, helps guide the clinical decision-making process and goal-setting. 

At the end of the day, these guidelines reflect the scenarios that we as clinicians face in IBD care. That makes it easier to integrate them into practice workflows. Once you do that, you can create dashboards to see how well you’re doing in your center or practice 

Narrator 

It’s great that we have these guidelines to support using IBD strategies in clinical practice! Dr Charabaty, are there any additional tools or resources you have used that would help other institutions implement treat-to-target strategies? 

Aline Charabaty 

Yes, definitely. Electronic medical records (EMRs) can be really helpful in implementing a treat-to-target strategy. With the EMR, we have the ability to automate reminders for tests and for follow-ups, which allows our staff to focus on communication, education, and patient care. For example, if I need labs to be drawn in 3 months and a colonoscopy to be scheduled in 9 months, inputting it into the EMR system helps ensure reminders are sent and the tests are done in a timely manner. No one has to rely solely on their memory.  And it really enhances the continuity of care for our patients. 

Narrator

What a great note to end on! This discussion has been incredibly insightful. Thank you so much, Dr Charabaty and Dr Barnes, for sharing your knowledge today, and thank you all for joining us as we explore this important topic! Together, we can improve care for patients with IBD. 

Thank you for listening! 

References: 

1. Noor NM, Sousa P, Paul S, Roblin X. Early diagnosis, early stratification, and early intervention to deliver precision medicine in IBD. Inflamm Bowel Dis. 2022;28(8):1254-1264. doi: 10.1093/ibd/izab228 2. Honig G, Heller C, Hurtado-Lorenzo A. Defining the path forward for biomarkers to address unmet needs in inflammatory bowel diseases. Inflamm Bowel Dis. 2020;26(10):1451-1462. doi: 10.1093/ibd/izaa210 3. Srinivasan AR. Treat to target in Crohn’s disease: a practical guide for clinicians. World J Gastroenterol. 2024;30(1):50-69. doi: 10.3748/wjg.v30.i1.50 4. Agrawal M, Spencer EA, Colombel J-F, Ungaro RC. Approach to the management of recently diagnosed inflammatory bowel disease patients: a user’s guide for adult and pediatric gastroenterologists. Gastroenterology. 2021;161(1):47-65. doi: 10.1053/j.gastro.2021.04.063 5. Lewis JD, Parlett LE, Funk MLJ, et al. Incidence, prevalence, and racial and ethnic distribution of inflammatory bowel disease in the United States. Gastroenterology. 2023;165(5):1197-1205.e2. doi: 10.1053/j.gastro.2023.07.003

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