by Dr Richard Hansen, CICRA Medical Director
Dr Hansen is a Consultant Paediatric Gastroenterologist and Honorary Clinical Associate Professor, Glasgow Children’s Hospital.
Here he reflects on advances made in paediatric IBD and the challenges that are gradually being overcome to get closer to as good as a cure.
I’ve recently been thinking a lot about the idea of a ‘cure’ for inflammatory bowel disease (IBD) - what do we mean by this word when thinking about IBD? What does it mean for Crohn’s disease, for Ulcerative colitis, and for the other forms of IBD we sometimes describe, like IBD type unclassified? The Oxford English Dictionary helps a lot here:
The sad news is we’re here at the beginning of 2018 and we’re not really any closer to that definition of cure than we were when CICRA was founded 40 years ago. There is however plenty of room for optimism, but we might first need to rebalance our idea of ‘cure’ and maybe rethink our aspirations about what we should be aiming for in IBD. One of the other definitions of cure set out in the Oxford English Dictionary is
Now this happens all the time in IBD practice in the UK. I’m happy to say this is a regular occurrence in almost every clinic in the country. This is also something that’s definitely improved in the last four decades. It’s important to say though that it’s still not the only outcome we see, and we have to remain mindful of those with difficult journeys in IBD, particularly those who fail to respond to multiple treatments and those who need multiple operations. For those people, even this definition of cure seems fanciful.
This is however a target we can aspire to, often meet, and can aim to improve on in 2018 and beyond. Whether it’s really a ‘cure’ is up for debate - I think not, but who am I to argue with the dictionary? So, let’s make 2018 the year where we aspire to relieve the symptoms of IBD as much as we possibly can. And can we do this more than in previous years? I believe so.
Our earliest medical treatments have aimed at trying to suppress the immune system. I often talk about IBD drugs turning the volume down on the immune system - this is a reasonable parallel, if a little crude. As we’ve understood more about the immune system and have made discoveries about the genetic basis of IBD though, we’ve learned to focus more on what’s happening. Our newest generation of drugs, starting with infliximab, don’t just turn the volume down, but target one particular part of the music and turn this down whilst potentially leaving the rest of the music playing.
Say, for instance, you wanted to focus on the rhythm of a band so wanted to listen to them playing without lead vocals. This is sort of what infliximab does to the immune system, it takes the lead vocals out. The music is still discernible and as loud as before, but its fundamentally changed. Since infliximab, two other major drugs have arrived in adult IBD care and are starting to be introduced on an individual case basis in paediatric practice - vedolizumab and ustekinumab.
Extending my analogy, we could say that vedolizumab removes drums only and ustekinumab removes bass guitar. So, great you might think, this will transform things, and all will be better. Well, not exactly yet. We don’t have good tools yet to identify which patient will respond best to which drug, and certainly some types of IBD seem to respond differently to different approaches. Plus, we’ve decades of experience in using other ‘volume reducing’ drugs, just over a decade of experience of using infliximab, and even less experience with the newer drugs, so the reasons for not jumping straight to newer drugs don’t just relate to cost (though this is of course a factor), but to our familiarity with older drugs – how they work, what to expect from them, what side-effects to look for, how to monitor dosing and bloods, etc… all experience built and refined over decades and not easily or quickly replicated.
So just like our tastes and styles of music evolve over time, our approach to the medical management of IBD is changing too. More drug options with narrower and more specific effects, offering more options for treating these difficult, and yes, still incurable, diseases. But we have more and more to offer the difficult cases and we’ll hopefully see more and more of the ‘relief of symptoms’ version of cure in the coming years.
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