Crohn disease

Understanding the Windows of Opportunity in the Management of CD

There are two key windows of opportunity for the treatment of Crohn disease (CD): early in disease course and postoperatively, according to a presentation by Stephen Hanauer, MD, at the Advances in Inflammatory Bowel Diseases (AIBD) Regional in Baltimore, Maryland.

“One window for treatment is before the patient develops structural damage, which is considered early Crohn disease,” Hanauer, who is medical director at the Digestive Health Center at Northwestern Medicine in Illinois, said during his presentation. “Approximately 80% of patients actually have a bad prognosis. Among those with bad prognosis, we expect them to progress early.”

Since patients can progress early, treating a patient as early in the course of their disease as possible is important.

Data from clinical trials that evaluated treatment at earlier disease stage has shown that patients who received treatment in the early stage of disease had overall better outcomes than those who were treated at a later course of disease, according to Hanauer.

The second opportunity for treatment is postoperatively to prevent disease recurrence.

“The better course is to move to surgery rather than initiate a patient on their second or third biologic therapy if they have structural damage,” Hanauer said. “It is much better to do surgery then restart therapy then just restart therapy.”

Using a treat-to-target approach is also crucial in the overall management of CD, according to Hanauer. The ultimate goal with the approach is to reach mucosal healing, not just improve symptoms of CD.

“Symptoms are not the best endpoint. Healing will be a better endpoint,” Hanauer said.

Hanauer noted it can be difficult to achieve mucosal healing. “If the patient has bad structural damage to start, it will be difficult to overcome this.”

Key concepts in the treat-to-target approach include the following:

  • Assess for prognosis
  • Treat early
  • Treat effectively
  • Continue to reassess patients on a regular basis

 

Desired outcomes of the treat-to-target approach among patients with early disease include complete absence of symptoms, no disease progression, no complications or disability, and normal quality of life.

Desired outcomes of the treat-to-target approach among patients with late-stage disease include stabilization of noninflammatory symptoms, no progression of damage or disability, and improved quality of life.

“We need to set our therapeutic goals for individual patients,” Hanauer said. “Those goals include not only getting the patient to feel better, but also getting them to deeper remission. The deeper to remission, the better the long-term prognosis is.”

—Melinda Stevens

Reference:

Hanauer S. Management of crohn’s disease. Presented at: Advances in Inflammatory Bowel Disease Regionals. September 7, 2019; Baltimore, MD.