Inflammatory Bowel Disease: Patient-Centered Care for Best Outcomes

A VIRTUAL SYMPOSIUM HELD on optimizing care for patients with inflammatory bowel disease (IBD), held in conjunction with the Asembia Specialty Pharmacy Summit and included an esteemed panel and moderator. Rolf Benirschke, a former NFL placekicker and survivor of lifethreatening ulcerative colitis who now works tirelessly as a patient advocate, introduced this panel discussion and encouraged participants to ask questions throughout. Christopher Owens, PharmD, MPH, and Patrick Nichols, PharmD, began with the current treatment landscape for IBD and both delved into clinical pearls that specialty pharmacists can take to their own practice sites to maximize care for this population.

Roughly 3 million Americans are affected with IBD and may have either ulcerative colitis or Crohn disease, both of which are chronic, inflammatory conditions. Despite the 2 major distinctions of IBD, these conditions may be further segmented, meaning they can differ dramatically in terms of severity, clinical course, prognosis, and response to treatment. Although researchers have not found an exact pathophysiology for the underlying inflammation, they suspect it is multifactorial with genetics, the gut microbiome, environmental and lifestyle factors, and the immune system all playing significant roles.

Treatment options and approaches for IBD have significantly evolved over the years. There are now oral, intravenous, and subcutaneous options. Benirschke discussed the challenges that he faced due to limited treatment options when he was first diagnosed with Crohn disease in the late 1970s. Clinicians have a much larger assortment of drugs and biologics from which to choose, with older medications being supplanted by biologics and oral Janus kinase inhibitors.

Owens differentiated that older approaches to treatment that considered either “top down” or “step up” strategies, but that newer guidelines highlight taking a more individualized approach to risk stratification and prognostic factors. He also highlighted the concept of “treat to target” in which clinicians aim to improve subjective symptoms as well as objective markers of inflammation. He reviewed the CALM study (NCT01235689), which looked at 244 patients with Crohn disease and found that tight control as measured by both biomarkers and symptoms resulted in better clinical and endoscopic outcomes than symptom-driven decisions alone. This supports early and aggressive treatment.

Owens' clinical pearls reminded participants to watch for injection site/infusion reactions and screen for preexisting infections, all while remaining vigilant for adverse effects and working with patients and providers to optimize outcomes. Among other points, he said that prescreening and conducting thorough medication reconciliation are critical in patients with heart failure. He also emphasized the importance of necessary immunizations, depending on the medication to be used and patient-specific factors.

Patrick Nichols, PharmD, spoke to the concerns that specialty pharmacists voice most often. He encouraged participants to learn the key differences between certain medication formulations—some will affect specific parts of the gastrointestinal tract predominantly—so they can make sensible recommendations.

Nichols said that specialty pharmacists who understand how to switch to biosimilars or agents that target specific areas of the bowel and how to obtain required approvals can lead the team, as many health care providers in IBD have limited knowledge on the topic.

He also discussed an emerging concern that switching to a biosimilar can lead to a “nocebo” effect. He described nocebo effect as negative expectations of the switch if patients’ reference drug has improved symptoms substantially. Nocebo effect can potentially lead to drug discontinuation in real-world settings, so specialty pharmacists need to manage patients’ expectations thoroughly.

Nichols’ clinical pearls stressed monitoring closely for nonadherence and tracking opioid use, prior biologic experience, and smoking status. Encouraging smoking cessation is important for all patients, but in patients with IBD, identifying appropriate treatment options can be critical to treatment success.

The panel concluded by saying that 1 approach does not fit all in IBD. As more data accumulate on the role of the gut microbiome, immunologic factors, stress and lifestyle factors, the use of biomarkers to guide treatment, and the positioning of new drugs and biologics currently in development as well as existing agents being studied head-to-head and in combination, clinicians will have even better guidance to more appropriately treat patients with IBD. Specialty pharmacists have a very important part to play in helping patients manage their condition, providing them with education and motivation to remain adherent, monitoring for treatment efficacy and adverse effects, and helping to select cost-effective therapies. Specialty pharmacists will undoubtedly find new opportunities to even further individualize care for patients with IBD.