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AGA creates tool for evaluation, treatment of Crohn’s disease
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The American Gastroenterological Association has developed a clinical decision tool to aid gastroenterologists in identifying and managing patients with Crohn’s disease.
“As health care systems move toward providing better quality care, it is important for gastroenterologists to have clinical support tools that will help them treat underlying disease, as well as the whole person,” William J. Sandborn, MD, division of gastroenterology, Inflammatory Bowel Disease Center, University of California, San Diego, and author of the clinical decision tool, said in an AGA press release. “This clinical support tool represents a big step forward for the treatment of Crohn’s disease and was created using a rigorous review process.”
William J. Sandborn
According to the release, researchers developed the “Identification, Assessment, and Initial Medical Treatment in Crohn’s Disease Clinical Decision Support Tool” by performing a literature review of the most recent data and creating a practical algorithm, Both components were designed to help clinicians evaluate patients for active inflammation and comorbidities, risk-stratify patients and apply appropriate therapies based on the AGA document, ‘Guideline on the Use of Thiopurines, Methotrexate, and Anti-TNF-a Biologic Drugs for the Induction and Maintenance of Remission in Inflammatory Crohn’s Disease.’ ”
“With the well-justified push toward providing better value in health care,” Sandborn wrote, “we will ultimately need to have clinical support tools that focus on treating the underlying disease as well as the whole person, quality improvement programs that focus on reducing practice variations related to these clinical support tools, and cost utility analyses to help us better select therapies that provide value to patients and to society.”
Disclosure: See the study for a full list of relevant financial disclosures.
Perspective
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Bret A. Lashner, MD
Crohn’s disease is a very heterogeneous disease; there are many different presentations, clinical courses and therapeutic options, so it is very difficult to create one or a series of algorithms to try to explain the best way to treat CD patients. However, if anybody can do it, it is William J. Sandborn, MD, who is clearly an expert in CD treatments. He did his best with this AGA publication to try to come up with a useful algorithm to assess and treat a majority of patients with CD, and I have to applaud him for this effort. However, my overall assessment is that there are some holes in it that would need to be addressed before these algorithms can be adapted for general use.
For example, he makes a point early on that a goal for treating patients with CD is to induce a deep remission, or total mucosal healing, which I agree with, but he does not talk about what to do once mucosal healing is achieved. Is that a time to step back from biologic agents and see how people do without them while on safer therapies? He mentions that patients should just be continued on anti-TNF agents indefinitely, so I am not certain what the advantage is of achieving a goal that does not result in a change in therapy.
Another group he did not address is postoperative patients. Once you have taken out a section of affected bowel, and basically there is no CD left in the body, we know that CD comes back very often, but there are different postoperative options to minimize your chance of recurrence. And as I first mentioned, there are many different behaviors of disease — inflammatory disease, stricturing disease, fistulizing disease — which he mentions in algorithm D, but he does not talk about how these different behaviors are treated differently. I get the feeling from reading this algorithm that he is concentrating on inflammatory-type behavior and ignoring strictures and fistulas. The other glaring problem with this is there is no mention made of the side effects of anti-TNF agents. Based on this document, almost everybody should be getting anti-TNF agents, which is one way to treat IBD patients, but there are many patients who will not agree to these medications because of the formidable side effects, so that needs to be factored into clinical decision making. What do you treat patients with who have had side effects from anti-TNF agents or refuse them due to the possible side effects?
While this algorithm is an excellent effort to try to unify treatment for a very heterogeneous disease, there are some problems with it. My overall feeling is there is too much emphasis placed on the use of anti-TNF agents, basically over the lifetime of disease, with no effort made to pull back once these medications have been started.
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