Russell D. Cohen, MD, on the Evolution of IBD Management

The management of inflammatory bowel disease (IBD) is evolving. Currently, health care providers commonly address the treatment of IBD based on how a patient is feeling at that specific point in time. However, the approach to treatment is becoming forward-thinking, with practitioners choosing treatment paths based on how a patient’s disease will likely develop in the future.

Russell D. Cohen, MD, professor of medicine at the University of Chicago Pritzker School of Medicine, director of the Inflammatory Bowel Disease Center, and codirector of the Advanced IBD Fellowship Program at the University of Chicago, will address this evolution during his keynote address at the Advances in Inflammatory Bowel Diseases (AIBD) Regional Meeting in Boston. Ahead of his session, Gastroenterology Consultant caught up with Dr. Cohen to talk about the importance and challenges of this evolution.

Gastroenterology Consultant: How has the management of IBD evolved over time?

Russel Cohen: Health care providers used to ask patients how they are feeling and then decide on a therapy based upon how active the inflammation was. Then, if the patients said they felt fine upon their return, providers would recommend the patient continue the treatment. If the patient did not feel well during the follow-up, the provider would change an aspect of the treatment. While we certainly do care how patients feel, it turns out that because both Crohn disease (CD) and ulcerative colitis (UC) are slow-acting, chronic inflammatory conditions, even though patients feel better, their disease may still be active or progressing. So, the modern evaluation of patients with CD and UC has changed to not only include how patients are feeling, but also include objective measurements of their CD or UC such as elevated inflammatory markers in the blood and stool, fever, or whether active inflammation is seen during a colonoscopy or similar type of scope.

GASTRO CON: What needs to be done in order to ensure patients, providers, and other health care stakeholders are on board with objective measurement in the management of IBD?

RC: Patients who feel well have to be willing to do evaluations that may not always be comfortable, such as a colonoscopy or blood tests. In order to explain the importance of these evaluations, the analogy that we have used for many years is related to changing your car’s oil. You change the oil in your car before the engine fails because you know that if you don’t, the engine is going to fail. In the patient scenario, we say we need to evaluate to determine what is going on to make sure that now, while we still have a chance to do something, we can “change your oil”— ie, adjust your medicine. I tell patients that the investment in blood tests, stool tests, scopes, and x-rays at this point, even if you are feeling well, is worth it because we can then see if the disease is actually active. It is much easier for us to intervene when things are only mildly irritated rather than waiting until a full-blown flare of the disease.

Insurance payers also have to understand that just because a patient is feeling well does not mean that evaluations—to prove the disease is under control and not progressing—should not be paid for. Similarly, health care providers need to realize that they will need to be more proactive in their evaluation of patients. 

GASTRO CON: As IBD management evolves, are there any previous management aspects that should not be overlooked, or any new aspects providers should pay particular attention to?

RC: The patient is the most important part. As IBD management evolves, not only should the objective findings be used in treatment decisions, but also how the patient feels. The patients’ feelings and interests need to be part of the formula. The other caveat to keep in mind is that patients are understandably concerned about the safety of either the evaluations or the treatment. Practitioners will sometimes have to consider how much more they will actually discover from additional tests. Also, if the medication a practitioner prescribes to a patient has concerning safety issues, and the scope only revealed that the patient had mild disease and he or she felt fine, we have to decide whether the medication is worth it at that point. These things need to be put into perspective.

GASTRO CON: What are the challenges to implementing this updated approach to IBD management, and what can be done to overcome these challenges?

RC: There has been an unfortunate rise of health care insurance companies refusing to allow completely approved processes or products because of the cost—even though the companies would actually save money when the patient gets well. The health care insurance companies are—despite what they claim—looking at short-term, bottom-line issues rather than long-term outcomes. This has been a big problem in the United States recently, and the trends are getting worse. Some of the previously best insurers are now some of the worst ones. The companies have created walls in which physicians cannot actually reach a medical person within the company in order to explain why the test or therapy is required.

Education is one element that is important in overcoming challenges. Clinical guidelines, which are regularly updated, are often helpful because they provide a reasonable approach that most of us would follow to evaluate and treat patients.

GASTRO CON: What do you want the main takeaway of your keynote to be?

RC: The main idea of the keynote is this idea of treat-to-target. We now have many effective, safe therapies. Instead of making patients earn the more effective therapies because they may cost more per dose, providers should start off with the best therapies—rather than the worst ones—for patients right away. That way, practitioners can prove that the patients are responding to treatment or that the disease is resolving or gone. If not, the therapy can be adjusted. Providers should also not forget about the fact that some patients will need surgery. Lastly, keeping the overall patient as the primary focus is the key, but we have to do it the 2019 way, rather than the 1980s way, which many of us were still practicing in not too long ago.