VIDEO: Positioning different therapies for ulcerative colitis

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 So, it's important when we talk about how do we position therapy to first recognize and be able to differentiate disease activity from disease severity. So, taking a step back, what's disease activity? Disease activity is how is your patient doing at the time of the clinical visit, at the time of the colonoscopy, at the time where you're performing the laboratory testing, including fecal calprotectin as an example. This is all an answer of how ill or how sick is your patient at that time, so a point in time. Disease severity includes prognostic factors. These are factors that tells us that if we don't control the burden of disease today, then our patients are at a higher risk for disease progression, at a higher risk for hospitalization requiring surgery or a colectomy, or having other complications.

So first, when we talk about positioning of therapy, we need to be able to appropriately identify the right patient for the right treatment, and for the right consideration of treatment. And so when you differentiate disease activity from disease severity, those prognostic factors need to come into play. So what are some of those prognostic factors? First of all, having the diagnosis of ulcerative colitis at an age of 40 years old or younger, that's one prognostic factor. Another is having extensive colonic involvement, or pancolitis, having severe endoscopic activity, so presence of those large deep ulcerations. Having presence of extraintestinal manifestations, or needing steroids, prednisone and/or having elevation in your biomarkers in that C-reactive protein or the fecal calprotectin. These are all factors that tells us that if you're at the younger age, extensive colitis, presence of extraintestinal manifestations, endoscopic activity that is demonstrating severe deep ulcerations, and having a high inflammatory burden with the elevation of fecal calprotectin or CRP, all of these prognostic factors tells us that we need to find the appropriate treatment for an aggressive phenotype, or aggressive type of ulcerative colitis. So really being able to differentiate that first and foremost is crucial before we determine how do we, and which treatment should we position or consider for our patients. Once we recognize that, then it's also important to be able to assess the component of how sick is your patient overall in a sense of are they knocking on the hospital bed door, or are they already hospitalized? How high risk are they for requiring urgent surgery or requiring a colectomy? And then again, the presence of the extraintestinal manifestations, having malnourishment, anemia, some of these additional factors needs to be considered when you're determining the right treatment for the right patients.