Q&A: ‘Everyone benefits’ from noninvasive, individualized monitoring in pediatric IBD
Key takeaways:
- Noninvasive monitoring could improve outcomes, reduce costs and minimize surgeries for pediatric IBD.
- Appropriate monitoring may also help compensate for ‘unreliable’ clinical symptoms.
SAN FRANCISCO — Noninvasive monitoring methods, such as enterography and ultrasound, are becoming increasingly recognized as essential tools in the management of pediatric patients with inflammatory bowel disease, according to presenters.
“Despite having an increasing number of treatment options, where we make a difference for our patients and improve their outcome is not necessarily just by the choice of medication, but by early treatment optimized by frequent monitoring,” Mallory Chavannes, MD, MHSc, FRCPC, FAAP, clinical director of the IBD program and assistant professor of clinical pediatrics at USC Keck School of Medicine, told Healio.
“This is where the field needs to continue to improve and figure out the best implementation algorithms and monitoring plans that are easy to apply widely and are also easy for patients to adhere to and follow through,” she added.
According to Chavannes and Jonathan R. Dillman, MD, MSc, who gave a presentation at Crohn’s & Colitis Congress, symptoms alone are not enough to assess disease activity and limitations exist with endoscopy, the current “gold standard” of monitoring. Noninvasive imaging methods may help mitigate those challenges.
“Despite being the reference standard, endoscopy has limitations,” Dillman, associate chief of research in the department of radiology and medical director of the Imaging Research Center at Cincinnati Children’s Hospital, told Healio. “The nice thing about ultrasound, MR enterography and CT enterography is they allow us to not only see the inner bowel wall, but also any deeper inflammation in the bowel wall and adjacent soft tissue, including fistulas and abscesses.”
Additional benefits of noninvasive monitoring by MR enterography (MRE), CT enterography (CTE) and ultrasound include their ability to guide more individualized treatment, improve long-term health-related outcomes and quality of life, and reduce corticosteroid exposure, Chavannes and Dillman told attendees.
In a Healio interview exclusive, Chavannes and Dillman expanded on these methods for monitoring and described which patients could benefit most from this type of care.
Healio: How do these noninvasive methods differ from other tests?
Chavannes: Disease activity can be monitored using blood tests, but these tests do not always correlate with the degree of intestinal inflammation and tend to not very specific biomarkers because they can be affected by other things.
What we have been trying to do in recent years is leverage more structural assessment or imaging to have a better picture of disease activity for IBD patients. Historically, we have been using a lot of MRE and CTE to a lesser extent, although newer protocols have decreased radiation exposure.
In the GI clinic, what we have been really trying to leverage, especially in the last 3 or 4 years, is using intestinal ultrasound at the bedside, because that can be very quick for certain patients, more so for recurrent than new patients, as well as for nonsurgical patients. It can be done during the clinic visit, so that there are no added appointments needed.
Dillman: While labs are important and work very well at the population level, for the individual patient there is often a disconnect; the same goes This is not only for labs, but also for clinical signs and symptoms.
Patients often feel improved, especially on treatment, and their laboratory values either normalize or substantially improve. But then we do imaging of the bowel using ultrasound, MRE or CTE, and there is continued bowel inflammation and ongoing damage.
Ultimately, if not addressed, this can lead to complications, including the development of strictures and penetrating complications such as fistulas and abscesses.
Healio: What are the benefits of noninvasive methods vs. endoscopy?
Chavannes: We have shown that having ongoing endoscopic disease activity is one of the drivers of disease complications for patients with IBD. But, in this population, access to endoscopy and time under anesthesia make endoscopy too long a procedure or unacceptable for a number of patients. Each noninvasive imaging modality has its own benefits and reliability compared with endoscopy.
CTE is as a rapid test and highly used in the acute care setting because it is quick, does not require anesthesia and provides good spatial resolution for assessing affected bowel segments, although it requires fasting, IV placement, contrast materials and radiation. It is not the best test for sequential assessment of a patient over time, but is very good for acute complications.
MRE, because it is nonionizing, is a better test for repeat examinations. It provides very good assessment of bowel wall and mesenteric inflammation and is very good at assessing the length of disease involvement, particularly in Crohn’s disease.
MRE has drawbacks, however, including the amount of time needed to obtain images and the need for fasting, IV placement and contrast materials. MRE protocols also commonly vary from center to center. Image artifacts may also occur in children who cannot follow commands or who are a little fidgety in the machine.
Intestinal ultrasound is another nonionizing option. We are actively training more and more gastroenterologists so that this test can be performed within the GI clinic. The beauty of that is it then becomes part of the exam during routine clinic visits, so we can assess for active intestinal inflammation right then and there, including monitoring for preclinical recurrence of disease.
Healio: Are there certain patients who may benefit more from this type of monitoring?
Dillman: I think all pediatric IBD patients benefit from some level of noninvasive monitoring once we have a confirmed diagnosis. We both agree that noninvasive imaging is not performed frequently enough in most patients. We can likely improve outcomes, lower health care costs and have fewer surgeries if we perform more frequent and individualized monitoring. How we do it may depend on the severity and extent of disease, patient age and local expertise.
Chavannes: Everyone benefits from ultrasound. Off the bat, I would say patients with Crohn’s disease tend to have very unreliable symptoms and often feel well when there is active disease or subclinical recurrence that we catch easily on ultrasound. This can also happen with ulcerative colitis.
Generally, patients tend to tolerate a lot of hardship when they have to, which is another reason why symptoms are not reliable. A patient-conscious approach to maximizing our clinic visits becomes very important to get all the information we can at that time.
Healio: What advice would you give providers who are hesitant to use these methods?
Dillman: It is increasingly recognized that superior outcomes in IBD can be achieved when patients are monitored appropriately using a combination of clinical assessments, labs, drug levels and noninvasive imaging.
An aspirational goals of the STRIDE-II guidelines was to assess transmural healing by imaging. It is likely that our best outcomes will be when deep remission is achieved, including clinical resolution of signs and symptoms, mucosal healing assessed by endoscopy and transmural healing assessed by MRE, CTE or ultrasound.
While we are not quite there yet, standardized monitoring — for example, follow-up MRE every year, ultrasound every 3 months, etc. — is the direction we are heading.
Healio: What else should our readers know about noninvasive monitoring?
Dillman: All of the monitoring tools we have talked about — endoscopy, noninvasive imaging methods, labs — are all complementary, and their use needs to be individualized to the patient. While a level of standardization is important, there remains the need for individual patient optimization and precision medicine.
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Chavannes M, et al. Clear signals: Noninvasive monitoring techniques for pediatric IBD. Presented at: Crohn’s & Colitis Congress; Feb. 6-8, 2-25; San Francisco.