Anita Afzali, MD, discusses treatment approaches to ulcerative colitis (UC) and how they may differ from Crohn’s Disease (CD).
David Hudesman, MD: Let’s pivot to UC. Anita, for a moderate to severe ulcerative colitis patient, how [effective] are these therapies that we just spoke about for Crohn? Is it same concept for UC? I know we have our small molecules, so what changes that?
Anita Afzali, MD: For moderate to severe ulcerative colitis—and I like how Miguel distinguished that for Crohn disease—the way I distinguish it for ulcerative colitis is I take the approach of, are they close to knocking on the hospital door or not? That’s the way I differentiate it simply with the patient. We’ve seen some of the worst left-sided sigmoiditis or pancolitis, but [it’s] seeing how sick they are, symptoms wise, where symptoms correlate with level of inflammation as compared to Crohn disease. I’m also looking at other markers, their albumin, CRP [C-reactive protein], calprotectin, and what that colonoscopy looks like. That’s how I differentiate and/or define ulcerative colitis as being moderate to severe as compared to mild. That’s my differentiator, the hospital door, and we now have a good medicine cabinet as well. We still have our TNFs [tumor necrosis factor inhibitors], so if they are knocking on that hospital door, I’m practicing combination therapy of a TNF with an immunomodulator; specifically, azathioprine. For the patient who is not knocking on the hospital door, mild colitis, or a patient who has bothersome symptoms but their biomarkers aren’t very elevated, the fortunate news is that we have time. Time is of essence, and in this situation I would choose vedolizumab, as an example. If it’s mild disease, this is where you could also consider your oral molecule, your S1P, as an example. Those are my differentiators of how close. From there, [I’m] determining if I need to start combination TNF with an immunomodulator or if I’m looking at a non-TNF [therapy]; specifically, vedolizumab or an S1P. The JAK [Janus kinase] inhibitors are an option for us, but these would be [for] patients who are intolerant or refractory or are exposed previously to a TNF. So we have to be mindful of that.
Transcript edited for clarity.