The right drug for the right patient

The ever-increasing armamentarium for the treatment of inflammatory bowel disease (IBD) poses an 'embarrassment of riches', as Dr Charlie Lees (Western General Hospital, United Kingdom) put it. He discussed stratification by disease biology to choose the right drug for the right patient.

It has been neglected for too long that IBD is progressive, according to Dr Lees; the typical pattern being: Patients are diagnosed with active disease, remission is induced but without properly controlling inflammation, the disease will flare and evolve over time. “Once we realise we must not only treat symptoms but also underlying inflammation, we can finally change the natural history of the disease course and offer our patients a much better outlook,” he said. “This means treating early, reducing flare rate, and getting close to a cure for some of our patients. Therefore, early control is everything.” Proof for this concept has emerged from numerous studies of drugs emerging after anti-TNF.

However, not every patient needs a biological and/or maintenance therapy. How to stratify those patients who do? Dr Lees believes that “turbo-charged treat-to-target with precision medicine” is the right strategy no matter what the choice of therapy will be. Three steps are essential:

1. Stratify therapy by risk factors, such as smoking, extensive small bowel disease, and peri-anal disease. New ways to help stratification in a less 'crude' manner are emerging. Genetics are not yet the answer because there is no clinical utility yet. Another way is using transcriptomics, which seem to become clinically meaningful already. The results of the ongoing PROFILE trial (www.crohnsprofiletrial.com) will be very important.
2. Stratify by biology. Dr Lees: “Will we go for head-to-head trials, and/or allow ourselves the scientific luxury of going back to disease biology to properly understand how to stratify the choice of our medication?”
3. Prevent disease flair. Dr Lees mentioned the PREdiCCt study (www.predicct.co.uk) he is involved in, which looks at how environmental factors, diet, and the gut micro-organisms influence IBD flare and recovery.

 



Posted on 9 May, 20198 April, 2024