Switching Therapies in Ulcerative Colitis

Miguel Regueiro, MD: Dave, when do you decide you need to change treatments, and Ellen, what are we still missing with our UC [ulcerative colitis] therapies? Dave, let’s go to you first, how do we know when we need to change a treatment?

David P. Hudesman, MD: I’ll break it up into 2 things. The first question, when Ellen was going over the mesalamines, one of the hardest questions for all of us is when do we pull the trigger? We have a lot of nice data in Crohn disease and some in UC showing that, bottom line, the earlier you start one of your biologics, or small molecules, the better the outcomes you’re going to have. And the better the outcomes, the lower the cost. When we’re talking about sequencing, if you start early enough, and you exclude the severe patients, you have a good shot of doing well with any of those therapies. The key is starting early and basing that decision not only on symptoms, but how the colonoscopy works, have they been on steroids, and so forth.

When they’re on a therapy, whether they’re on a biologic or small molecule, and symptoms worsen, step 1 is confirming that this is active inflammation, that it’s not an infection they picked up while traveling and ate something. We talked about quality of life, if they have underlying stress and anxiety, is this irritable bowel syndrome or bile salt diarrhea? It’s making sure there’s active inflammation, biomarkers such as fecal calprotectin, or C-reactive protein, doing a sigmoidoscopy, and seeing what’s there. Then once that’s confirmed, you can make that decision. But usually, if you have somebody who has responded well initially to a therapy, I try to optimize that therapy before moving on, versus somebody who’s maybe never had a good response, then I’ll pivot sooner. I’m sure we’ll go into more detail about which therapy to start from and which therapy to switch to.

Miguel Regueiro, MD: One thing you said and I want to emphasize is, in general, and I’m not being specific to any one person, but we burn through our therapies too quickly. The concept of, if there is a response, to optimize it. If there’s truly no response, they’re failing, that’s one thing. Some of that gets into how we monitor therapies, and some of this fits into how we assess for improvements of disease. Like you said, we’re going to come back to this in abit, but that’s such an important point.

Transcript Edited for Clarity