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Dr. Burrill B. Crohn Professor of Medicine
Chief of the Dr. Henry D. Janowitz Division of Gastroenterology
Mount Sinai Hospital
Chief, Division of Gastroenterology
Mount Sinai Health System
Director, Digestive Disease Institute
Icahn School of Medicine at Mount Sinai
New York, New York
Bruce E. Sands, MD, MS, has disclosed that he has received consulting fees from Abivax, Arena, AstraZeneca, Bacainn, Boehringer Ingelheim, Boston Pharmaceuticals, Celltrion, Genentech, Gilead Sciences, GlaxoSmithKline, Index, Inotrem, Ironwood, Janssen, Kallyope, Lilly, Pfizer, Prometheus Biosciences, Prometheus Therapeutics, Surrozen, Takeda, Target RWE, USWM Enterprises, and Viela Bio and funds for research support from Theravance.
Historically, most gastroenterologists approached treatment for patients with inflammatory bowel disease (IBD) rather simply: Treat the symptoms, and if the patient feels well, continue that treatment. More recently, we have learned that the symptoms of IBD can be very deceptive. Although it is obviously very important to make patients feel better, they may not achieve the best long-term outcomes unless there is objective evidence of bowel healing. To that end, we should be thinking of cycles of care—where the cycle is a trial of therapy that is intended to achieve a therapeutic goal, and if that therapeutic goal isn’t met within a certain time frame, you make an adjustment. The treat-to-target approach aims to define what the appropriate targets of treatment are as well as the time frames in which you assess progress toward those targets.
In April 2021, the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD—of which I am a member—published an update to its consensus recommendations on treat-to-target strategies in IBD, known as STRIDE-II. With advances in novel biologic and small molecule treatment options, new diagnostics, and increasingly complex treatment algorithms, STRIDE-II updates previous STRIDE recommendations to help define reasonable treatment targets in the short term, intermediate term, and longer term. This includes the addition of new treatment targets, including clinical response, clinical remission, and C-reactive protein normalization as immediate-term and short-term targets and restoration of quality of life and absence of disability as long-term targets. STRIDE-II also incorporates a pediatric outcome, namely, normalization of growth. Moreover, expert opinion is provided as to how long specific drugs will need to be used to achieve particular outcomes.
Applying STRIDE-II in Practice
In practice, these evidence-based, consensus recommendations can help guide healthcare professionals toward improved treatment outcomes for patients with IBD. If a therapeutic goal has not been met within the recommended time frame, then an adjustment should be considered—switch treatments, adjust the dosing, and so on.
For example, the STRIDE-II consensus opinion is that a patient with Crohn disease who has initiated anti–tumor necrosis factor treatment should be assessed for clinical response between 2 and 4 weeks and clinical remission between 4 and 6 weeks, but normalization of C-reactive protein would not be expected until 9 weeks. Of course, clinical judgment should also be used; a patient who was more ill to begin with may take longer to reach these targets. Nonetheless, STRIDE-II provides a valuable roadmap of how to monitor outcomes while progressing toward the ultimate target of healing the mucosa.
There may be some practical barriers to implementing the recommendations of STRIDE-II. Assessing patients for objective outcomes over several months requires the use of colonoscopy or cross-sectional imaging. Not all patients understand that or want to undergo multiple colonoscopies in a 6-month period; it involves an invasive procedure and adds cost. Another barrier is managing expectations. No matter how much we try to achieve the ideal goal of absolute mucosal healing, it simply is not possible for every patient.
STRIDE-II offers an important update to defining and implementing a treat-to-target approach for managing patients with IBD. As the treatment landscape for IBD grows more complex, these practical recommendations will be a valuable resource for many healthcare professionals.
How do new recommendations from STRIDE-II influence your practice? Answer the polling question and join the conversation by posting a comment in the discussion section.