June Shannon speaks with Prof Jean Frederic Colombel, Professor of Hepatogastroenterology in Lille, France, about the latest developments in treating inflammatory bowel diseases.
The advent of biologic treatments for Inflammatory Bowel Disease (IBD) such as Crohn’s disease has been one of the biggest advances in the treatment of these and other chronic illnesses, a leading international IBD specialist has said.
Speaking to IMT during a recent visit to Dublin, Prof Jean Frederic Colombel, Professor of Hepatogastroenterology at Centre Hospitalier Universitaire (CUH) in Lille, France, said it was important for people to realise that IBDs were “not rare diseases” and that early diagnosis was linked with better outcomes.
“It is estimated that there are approximately 1.5 million people in Europe with IBD, in France approximately 200,000 and the incidence or numbers of new cases is still increasing, especially in adolescents, so it is a big problem,” Prof Colombel said.
According to the Professor, while IBDs are chronic diseases with low mortality, the morbidity associated with conditions such as Crohn’s or Ulcerative Colitis (UC) is quite high.
He said that the introduction of biologics for the treatment of IBD 15 years ago marked a big change in how these conditions were managed. Before the advent of biologics, patients were treated with anti-inflammatory agents, corticosteroids and immuno-suppressants.
“Biologics have changed the way of treating patients not only in IBD, [but] all patients with chronic diseases — it is the same for rheumatology, it is the same for neurology,” he said.
According to the French expert, the advent of biologics means that doctors now have “much more potent agents” that work not just to control symptoms, but to also prevent the progression of disease.
“In the past, we concentrated on treating symptoms; we were very happy when the patient was doing well clinically, but were ignoring the point that we need to treat beyond [the] symptoms if we want to avoid the damage caused to the gut by the disease.
“With these drugs, we are now able not only to treat symptoms, but to heal the mucosa… you are able to heal the colon or the small bowel, and if you are able to heal, you will prevent progression of the disease and the need for surgery,” he added.
Changed goals and strategies
Prof Colombel, who is currently the Chair of the International Organization for Inflammatory Bowel Disease (IOIBD) and former President of the European Crohn’s and Colitis Organization (ECCO), said that the advent of biologics had therefore changed the goals and strategies for the management of IBD, and it was now a matter of optimising the use of these new therapies.
However, he said it was also important to consider the side effects associated with biologics and the fact that they were very expensive drugs.
According to Prof Colombel, there are several side effects associated with biologics, however the two most important were the risk of infection, which he said was well demonstrated, and the potential long-term risk of cancer, which was “less well demonstrated” and unclear.
In relation to cost, he said that while biologics were very expensive drugs, they were cost effective in the long term. “If you use them properly; if you optimise them you will be able to avoid surgery, hospitalisation, work disability, pension disability and so on… I am convinced that in the long term, this would be cost effective for the society.”
The French professor added that to date there were two biologics approved in Europe — these were Infliximab and Adalimumab.
According to Prof Colombel, whereas in the past doctors may have had a tendency to reserve the use of new drugs as a last resort, and this was also true of biologics in IBD, it has now been shown that the earlier these drugs are used, the more effective they are.
“Biologics were kept only for patients who were failing first-line, second-line, third-line… but now it has been shown that if you use them very early, they are much more effective.”
However, it was important to note, he added, that no two patients were alike and therefore the therapeutic strategy needed to be tailored for individual patients based on a number of factors, including clinical symptoms and disease severity and extension.
“We have many parameters that we are using in order to decide which strategy we should use in what patient,” he said.
“It is all about disease extension. For instance, if you have disease involving the small bowel and the colon; if you have fistualising disease — these are very effective drugs. If you are scoping the patient and you see that the disease is very bad, with deep ulcers, you know that this patient needs very intensive treatment from the beginning,” he added.
More research needed
Asked if patients could remain on biologics long term, Prof Colombel said that this was something that to date was unknown and needed more research.
He explained that in France, they were looking at de-escalating strategies, where when a patient was in full remission after being on biologics, then after a certain period of time treatment could be de-escalated, which meant decreasing the dose or stopping the drug.
“This is still a matter for research. This is a very important question and the first one asked by the patient,” Prof Colombel said.
He believes that IBDs such as Crohn’s disease are best treated in an IBD centre of excellence, of which there were between 30 and 40 in France. In his view, Ireland also had some very good centres of excellence for IBD.
France also boasts one of the biggest IBD registers in the world, which has been collecting data on all new IBD cases since 1988 and currently has 25,000 cases on its books.
Interestingly, Prof Colombel said that the French IBD Register had now collected enough data to allow researchers to look at the possibility of the clustering of IBD in certain geographical areas.
Finally, Prof Colombel said that the future of IBD therapy could potentially involve patient profiling based on genetic and serological markers, which would allow treatments to be tailored according to the individual patient’s prognosis.