Inflammatory Bowel Disease Requires Patient-Health Care Team Partnerships
Treatment for inflammatory bowel disease (IBD) has the best outcomes when patients partner with their medical teams. With direct and indirect estimates of $31.6 billion or more annually, health care administrators and policy makers consider IBD among the most expensive of diseases. During a session at the Asembia Specialty Pharmacy Summit 2019, Christopher T. Owens, PharmD, MPH, teamed with Rolf Benirschke, retired National Football League (NFL) kicker and respected leader in the health care industry, to discuss IBD from varying perspectives. Their presentation made it clear that pharmacists are vital in engaging patients to ensure better experiences and successful outcomes.
Benirschke opened the session by sharing his difficult journey after having Crohn disease diagnosed during his second NFL season. He played for more than a year as his illness progressed, and he ultimately required ileostomy surgery. Remarkably, Benirschke was able to resume his NFL career, playing 7 more seasons, 4 while wearing an ostomy appliance. He has dedicated his life to advocating on behalf of patients, particularly those living with IBD or facing ostomy surgery.
Benirschke provided a brief overview of the limited treatment options available during his illness in 1978 and how, through research and innovation, treatment options today have expanded immensely, with more exciting therapies coming. Speaking from his own experiences, as well as from interactions with thousands of patients he has encouraged over the years, Benirschke discussed how important it is to develop effective communication with patients to engage them, especially so they can ask difficult questions.
Finally, Benirschke discussed the radical upheaval taking place in health care and how more informed and connected patients are critical to solving the challenges the industry is facing. Benirschke said that patients are now increasingly powerful consumers who demand more transparency from the system, ask to be included in the decisions that affect their health, and share their experiences with thousands of other patients via social media.
Owens primed the audience with a discussion of patient-centered care, reminding attendees that when clinicians and patients work together to make decisions, the likelihood of remaining adherent to therapy is much greater. He expanded the concept to encourage health care providers to include patients with IBD in planning when selecting tasks, creating treatment plans, and balancing risks and benefits, with an emphasis on patient preferences and values.
Specialty pharmacists have 3 key roles: educating patients, working with health care providers, and ensuring medication access.
“In the case of IBD, these 3 functions can be more complex than one would expect,” Owens said. “One of the first steps is to determine whether you are dealing with ulcerative colitis or Crohn disease. And, of course, the differential diagnosis would be inflammatory bowel disease.”
Based on data collected by the National Health Interview Survey in 2015, approximately 1.3% (3 million) of Americans have diagnosed IBD, which tends to be an adult diagnosis, usually identified between ages 20 and 40 years.
Researchers have not identified a single cause of the disease but instead indicate that genetic, microbiological, and environmental factors contribute to its development. On top of these 3 factors, infection and psychology can play roles.
Owens’ review of the disease highlighted clinical features, which include these symptoms: malaise, rectal bleeding, abdominal wall internal fistulas, and rectal involvement. He made it clear to audience members that IBD can erode quality of life. Patients can and do live full, productive lives but need considerable support from the medical system to do so in many cases.
Because IBD is incurable, patients need to understand the goals of their treatment plans. First, clinicians hope to induce and maintain remission. Next, they want to improve the patient’s quality of life. Third, they hope for mucosal and histologic healing.
Owens reviewed the various traditional treatment options before moving on to newer options. Among them is the Janus kinase inhibitor tofacitinib, an oral small molecule that can be dosed twice daily.
Owens noted that the introduction of biologics more than 20 years ago revolutionized IBD treatment. He said that patients may lose response to anti–tumor necrosis factor agents if they develop antidrug antibodies. Some evidence also suggests that lower trough levels of the biologic may contribute. In September 2017, the American Gastroenterological Association Institute recommended considering target trough concentrations for certain biologics and screening for antidrug antibodies.
Owens reiterated that treatment strategies must be developed in collaboration with the patient. Among the important considerations are the type of IBD (Crohn or ulcerative colitis), the patient’s age, disease severity, disease duration, and prior treatments.
IBD is undergoing a paradigm shift as clinicians across the country realize that earlier diagnosis and better access to effective treatment options are critical. Each patient needs to be treated to a realistic target that includes prevention of disease progression and understand the necessity of a good vaccination schedule.
The audience was all ears as Owens discussed the role of biosimilars in IBD. He reviewed the differences between biosimilars and the reference products and noted that all of us need to monitor the growing clinical data that support equivalency between biosimilars and branded biologic products.