Caring for IBD patients in an interdisciplinary team

19.11.2021 10:37

The GastroDialog - Takeda's interactive training program - took place for the 7th time in 2021. 210 doctors and 100 medical assistants (MFA) took the opportunity to scientifically examine relevant and exciting topics relating to chronic inflammatory bowel diseases, discuss them and transfer them into everyday professional life. According to Takeda, the goal is to work together as a team to ensure the best possible care for patients.

The chronic inflammatory bowel diseases (IBD) ulcerative colitis and Crohn's disease are complex, chronic diseases. “In order to provide optimal care, intensive collaboration between a multidisciplinary team – consisting of doctors from various disciplines and trained medical assistants – and the patients is necessary,” says Prof. Andreas Sturm, Berlin.

Patient empowerment is best achieved in a team

According to Sturm, the medical tasks include making diagnoses, endoscopies, drawing up a therapy plan and prescribing medication. “For example, specialist assistants take care of organizing check-up appointments, informing the patients, administering medication, identifying possible undesirable events at an early stage and arranging contact with the therapists,” says Sturm. According to Sturm, the good collaboration between doctors and MFA has resulted in, among other things, better adherence to therapy and an improved quality of life for patients - at the same time, the number and duration of doctor contacts could be reduced. “Patients also benefit from multidisciplinary care, for example with fewer or shorter hospital stays,” emphasized Sturm.1

Different approaches to IBD therapy – selective vs. systemic effectiveness

“In everyday clinical practice, IBD are very heterogeneous diseases in which the extent of inflammation
and the occurrence of stenoses and/or fistulas can vary greatly,” emphasized Prof. Markus Neurath, Erlangen, and therefore welcomed the growing number of available therapy principles. “Today, tumor necrosis factor alpha (TNFα) antagonists are available for IBD treatment. “They reduce the inflammatory process by inhibiting TNFα in the intestine, but also have systemic effects through the circulation in the body,” said Neurath and added: “In addition, the selection of cells that are highly resistant to TNFα seems possible. This new immune phenotype then no longer responds to anti-TNFα therapy.”2 In contrast to TNFα antagonists, Janus kinase (JAK) inhibitors modulate the signal transduction of a whole range of cytokines simultaneously. The positive and negative effects of the individual JAK inhibitors are determined by the selectivity of the active ingredient for the four different Janus kinases - JAK1, JAK2, JAK3 and TYK2, explained Neurath.3,4

Vedolizumab – an intestinal-selective α4β7 integrin antagonist

The humanized monoclonal IgG1 antibody vedolizumab (Entyvio®) has a selective effect in the gastrointestinal tract. Inhibition of the interaction of α4β7 with MAdCAM-1 by vedolizumab prevents the migration of intestinal infiltrating T lymphocytes and thus regulates the inflammatory response.5

Neurath made it clear that vedolizumab does not have systemic immunosuppressive activity using current data on vaccination response to a corona vaccine in IBD patients: Patients receiving infliximab showed significantly lower seroconversion rates than those receiving vedolizumab - regardless of the vaccine used and regardless of whether At the same time, other immunomodulators were used.6

Three aspects for the treatment decision – evidence, preference and eminence

Prof. Axel Dignaß, Frankfurt/Main, emphasized that a number of guidelines are available for the treatment of ulcerative colitis and Crohn's disease - including those from the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the European Crohn's and Colitis Organization (ECCO).7-10 “Unfortunately, the guidelines are often inadequately implemented. For example, oral corticosteroids have often been used for too long.”11 Dignaß cited the partial lack of up-to-dateness and implementation of the guidelines in everyday practice as well as the lack of evidence and recommendations for special situations or patient groups such as: B. old or multimorbid patients. “The pilot project of the 'Living Guidelines' of the DGVS and the AWMF, for example, can bring improvements here. A complete update of the guidelines takes place every five years, as well as an annual evaluation and, if necessary, adjustments for clinically relevant innovations,” explained Dignaß. “For good therapy”
Decisions are therefore not only based on the existing evidence and the recommendations of the respective guidelines, but also on the expertise of the treating person. “Patient preference also plays an important role in the treatment decision,” he added. Dignaß recommends that diagnostic and therapeutic decisions should therefore be regularly questioned together with the patient.

Outlook for IBD therapy of the future

Finally, Prof. Stefan Schreiber, Kiel, gave an outlook on the IBD therapy of the future and made it clear that, in addition to biologics and small molecules, numerous other therapeutic approaches would be conceivable in the future - for example modulation of the microbiome and nutritional interventions as new basic or additional therapies, epigenetic Approaches to address gene therapy and immunometabolism as therapeutic goals. “Some of these approaches are already in clinical research,” says Schreiber. Overall, the efficiency of IBD treatment will certainly be increased: not only through new active ingredients but also through sequential therapies and the use of biomarkers to better control the use of medication. In addition, wider availability of effective therapies for doctors must be guaranteed and disease control must be established as a therapy goal - not least in order to make healthy aging possible for IBD patients beyond intestinal inflammation, demanded Schreiber.

“In any case, direct comparisons of the various therapy options, such as those available with the VARSITY study12, are important for therapeutic progress.” The multicenter, randomized, double-blind, active-controlled phase 3b study in a double-dummy design was the first head-to-head study to directly compare two biologics approved for the treatment of ulcerative colitis: the TNFα blocker adalimumab sc and vedolizumab iv. Included were 769 adult patients with moderately to severely active UC.12 The study showed a Superiority of vedolizumab over adalimumab in terms of clinical remission‡ at week 52 (31.3 % vs. 22.5 %; p = 0.006) and mucosal healing§ at week 52 (39.7 % vs. 27.7 %; p < 0.001).12

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4 Jamilloux Y et al. Autoimmune Rev 2019; 18(11): 102390
5 Technical information Entyvio®. As of: March 2021
6 Kennedy NA et al. Good 2021; 70(10): 1884-1893
7 Sturm A et al. Updated German S3 guideline “Diagnostics and treatment of Crohn’s disease”.
Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS).
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