Acceptability of a ‘treat to target’ approach in inflammatory bowel disease to patients in clinical remission

1. Christian Selinger1,2,
2. Jenelyn Carbonell1,
3. John Kane1,
4. Mandour Omer1,
5. Alexander Charles Ford1,2

Historically the goal in inflammatory bowel disease was to enable the patient to have absence of symptoms, ideally in the absence of requiring glucocorticoids. Relatively recently the goal posts in the treatment of IBD has changed with the concept of ‘treat to target’. For those not familiar with this concept, “treat-to-target” is based on identification and specific definition of appropriate treatment targets, using available evidence. There are conditions in where treatments targets have been well defined such as hypertension….you must have a BP below 140 systolic or you are at risk of strokes, myocardial infarctions etc….what has been less clear however are acceptable treatment targets in inflammatory bowel disease with some advocating normalisation of biomarkers, others clinical factors, some mucosal healing and even histological healing as what we should be aiming for.

To help us identify which targets we should be aiming for in IBD an expert group put together the stride consensus or its longer form The Selecting Therapeutic Targets in IBD (STRIDE) consensus. In this consensus the target agreed that we should be aiming for in IBD was mucosal healing. The reason for this target is based on the understanding that even when patients feel symptomatically well, there may still be ongoing inflammation. This ‘silent’ inflammation is a risk factor for all sorts of complications such as hospitalisation, the need for surgery and even cancer.

The potential problem in IBD is in order to achieve this target of mucosal healing it is likely that the patient will be required to undergo close monitoring which may include regular bloods, biomarker assessment and endoscopic evaluation. Whilst this all seems great….we can reduce inflammation, stop disease progression, halt the disease….one must question at what cost does this goal come to a patient’s overall quality of life and more importantly are such approaches acceptable to a patient with IBD?

This was for me a really novel paper that explored things from a patient’s perspective and not just explored outcomes based on what we tell a patient they should be doing. In this UK study they recruited 298 patients in clinical remission from their IBD consisting of (145 males; 48.9%) including 144 with CD (48.3%), 136 with UC (45.6%) and 18 with IBD-unclassified (IBD-U) (6.1%). They then interviewed these patients for 30 minutes using a variety of validated questionnaires and furthermore assessed patients perceived acceptability of a treat to target approach for their IBD.

For me the results are really important and maybe surprising…. They found that overall, 66.2% of patients rated a treat to target approach as acceptable meaning that in up to a third of patients they remain unconvinced by the benefit of a more closely monitored approach. What I found most interesting was that in the patients that were on a second-line anti-TNF, were less likely to agree to a treat to target approach (p=0.012). I speculate that these patients may be fed up with all the investigations that they have already had to get to their second line biologic. It is plausible to me that these patients may accept a higher risk of adverse disease outcomes at the ‘luxury’ of a greater freedom from yet another test and more time in hospital…It must always be remembered that a doctors job where possible is to help facilitate the best quality of life for a patient….sometimes allowing them to skip a colonoscopy that year, for some may be the best Christmas present you can buy them.

I think like in all things in life, a balance must be met. A disease is part of that person, that person will have a life, one that their disease has already likely impacted on in some way. It is therefore important to weigh up the different treatment approaches with all our patients and take an individualised approach. From a clinical perspective I am convinced that there is enough evidence to tell us that treat to target in IBD gives the best outcomes, however, this study is a timely reminder that patients don’t always agree with what the doctor thinks is best for them….and sometimes despite all our good intentions….it’s not best for that patient.

Want to read the whole paper…. I think you should…

https://fg.bmj.com/content/early/2020/01/24/flgastro-2019-101366