Experts summarize their clinical strategies for monitoring and treating patients with Crohn’s Disease (CD).
David Hudesman, MD: This was a great discussion about Crohn disease.Just to summarize for our moderate to severe patients, more on the moderate end, luminal one segment, we’re talking about ustekinumab, risankizumab, and vedolizumab. And in the more severe patients, perianal patients, anything that worries us; diffusible bowel disease, multiple segments, that’s when [we use] TNF [tumor necrosis factor inhibitors] and chemotherapy, deep ulcers. Second-line therapy, as Miguel said nicely, depends on what you started with. It’s usually TNF to a 12/23 or 23, or vice versa. Monitoring your patients closely based on symptoms, based on biomarkers, helps determine—and that’s the hardest question—how long do you push? But that monitoring will help guide us there.
Millie Long, MD, MPH: David, my practice has evolved over the last several years in that I didn’t use fecal calprotectin that much; it wasn’t well covered from an insurance standpoint, but the times have changed. We now have better thresholds, better data. We even have better data understanding in the postoperative state what a fecal calprotectin can do and inform us on in terms of a noninvasive marker of a recurrence. I am using this much more in my practice, and I’d encourage our audience to do so as well. I check it at the time when the patient’s not doing well and I’m scoping them; you can benchmark it, you can know what that measure is and then you can follow them and it becomes a great way, another added data point to help.
Miguel Regueiro, MD: It picks up small bowel inflammation. There was this theory out there initially that it’s only good for colon, but Millie, to your point, it’s any gastrointestinal inflammation. Pairing it [with] a CT or an ultrasound or colonoscopy, so you know if it’s high, you know what to follow. The flip side is there are some patients where it doesn’t quite go as high as you would think, and they have severe disease, and then those are the ones [with whom] you need to take caution. But I am exactly like you; I’m using it a lot more now than I ever have in Crohn and ulcer.
Millie Long, MD, MPH: In both, yeah. I’ve found that you don’t see quite as high numbers with small bowel inflammation, you can see massive numbers with colonic inflammation, but it’s still something to follow, and it tracks. As long as you benchmark it, it’s OK.
Maia Kayal, MD: A lot of centers are now incorporating, as you mentioned, Millie, intestinal ultrasound, and benchmarking it, similarly with a calprotectin or a scope, so that we’re trying to head toward more of a minimally invasive, tight control monitoring strategy for our patients so that we’re not impacting their quality of life too much. If they’re in the clinic for a visit and they’re describing new symptoms, you want a quick way to assess their disease activity so that you understand, is this more functional, is this more inflammatory. Intestinal ultrasound has given us the freedom to do that during the visit as a quick point-of-care test. That’s something that we’ve incorporated into our clinical practice. It’s just another target that you’re trying to use, and how you’re tweaking your medications. Many centers now are incorporating it. Europe was way ahead of us in this, as they are in many things, and we’re slowly catching up, but it’s been nice to see how in the US, it’s been exploding across the center, the use of intestinal ultrasound.
Transcript edited for clarity.