Positioning Medications in Crohn Disease, with Teddy Solomon, MSN, NP

The management of Crohn disease (CD) has evolved significantly in recent years, driven by advancements in pharmacologic therapies and a deeper understanding of disease pathophysiology, with the current treatment landscape including conventional immunosuppressants, biologic agents, and small molecules.

Recently, the CD treatment armamentarium grew with the US Food and Drug Administration approvals of risankizumab (Skyrizi) in 2022 and upadacitinib (Rinvoq) in 2023.1,2 Now, with more treatment options than ever, a comprehensive approach to positioning these medications is especially crucial for optimizing patient outcomes.

Teddy Solomon, MSN, NP, a nurse practitioner at Cedars-Sinai Medical Center, gave a presentation about positioning medications in CD at the 2024 annual Gastroenterology and Hepatology Advanced Practice Providers (GHAPP) conference in National Harbor, Maryland. The editorial team of HCPLive Gastroenterology sat down with Solomon for more insight into his talk and considerations for navigating the different treatment options available for patients.

HCPLive: Can you explain the current landscape of Crohn’s disease management, and where medication positioning fits in this continuum of care?

Solomon: We have made significant progress since infliximab, the first advanced therapy for Crohn’s disease, was approved over 20 years ago. Since 2022, 2 new therapies have been approved, with more on the way.

While having more treatment options is beneficial for patients, it can also be challenging as a provider to determine the best choice, as medication selection is not a one-size-fits-all process. To select the most appropriate therapy, we must adopt an individualized approach, considering various factors such as the patient’s disease phenotype, risk factors, social circumstances, disease severity, and preference for medication administration. By taking these factors into account, reviewing current guidelines, and engaging in a thorough discussion with the patient, we can determine the most suitable medication for our patient.

HCPLive: How do you navigate the different treatment options available to patients, especially when you’re looking at potential first-line options and the factors that go into that decision for each patient?

Solomon: When choosing a medication for a patient with moderate to severe Crohn’s disease who is biologic-naïve without fistulizing disease, there are several options to consider. According to the most recent AGA guidelines, infliximab, adalimumab, and ustekinumab are strongly recommended for inducing remission, while vedolizumab is conditionally recommended over certolizumab pegol. Although risankizumab was not approved by the time the current Crohn’s disease guidelines were published, its similar mechanism of action to ustekinumab makes it a reasonable first-line option.

If the patient were to have fistulizing Crohn’s disease, we have the most data to show that infliximab at higher maintenance trough levels >20 would be the best first-line therapy for this phenotype of patients. When deciding on the best therapy, it is important to consider these recommendations along with individual patient factors.

HCPLive: What role does patient education and shared decision-making play in your process of positioning medications for long-term disease management?

Solomon: It is critically important to involve patients in the decision-making process when starting or switching therapies. Patients should feel comfortable with the medication prescribed and understand not only the frequency of administration but also the reasons behind the recommendation. This understanding fosters better medication adherence, which in turn enhances treatment outcomes. Providing data on the effectiveness of treatment options, the patient's specific disease characteristics, and the safety profiles of available medications can facilitate a collaborative decision between the patient and provider, leading to the best possible next step in treatment.

HCPLive: What role do you see combination therapy playing in Crohn’s disease management in the future?

Solomon: The concept of combination therapy is not new to inflammatory bowel disease. The SONIC trial demonstrated that patients receiving infliximab in combination with azathioprine were more likely to achieve clinical remission compared to those on either therapy alone. In clinical practice, mercaptopurine or methotrexate can also be used in a similar combination approach with an anti-TNF.

More recently, the VEGA proof-of-concept trial has shown that combining guselkumab with golimumab may offer greater efficacy in ulcerative colitis than using either drug alone. Additionally, the DUET study, which is currently in clinical trials, is exploring the combination of these therapies in both ulcerative colitis and Crohn’s disease.

Despite the availability of various treatment options targeting different inflammatory pathways, patients with severe, refractory disease may benefit from combination therapies that leverage multiple mechanisms of action to better control disease activity.

HCPLive: Is there anything else from your talk at GHAPP you’d like to highlight?

Solomon: I often observe that patients tend to overestimate the safety risks associated with our approved advanced therapies for Crohn’s disease while underestimating the risks of multiple courses of steroids and uncontrolled disease. It is crucial to recognize that uncontrolled Crohn’s disease itself constitutes an adverse event and can lead to a range of complications.

References

1. ^{Walter, K. FDA Approves Risankizumab For Crohn’s Disease. HCPLive. June 17, 2022. Accessed September 12, 2024. https://www.hcplive.com/view/fda-appropves-risankizumab-crohns-disease}
2. ^{Walter, K. FDA Approves Upadacitinib for Patients With Crohn's Disease. HCPLive. May 18, 2023. Accessed September 12, 2024. https://www.hcplive.com/view/fda-approves-upadacitinib-patients-crohns-disease}