Op-Med is a collection of original articles contributed by Doximity members.
More than 2,100 attendees registered for the virtual conference. Most main sessions were attended by more than 500 participants. The technical aspects were outstanding. There was nary a glitch in any of the components which is remarkable since the tech support was delivered from Belgium. The fact that the majority of the sessions were pre-recorded assured excellent quality for the presentations and the live, moderated discussion were all both lively and diverse with multi-specialty participation from gastroenterologists, surgeons, pediatricians, health psychologists, and dieticians. Our ambassadors were ubiquitous throughout the meeting from the planning, abstract reviews, presentations, service on panels, and, of course, on social media. Twitter was alive with AIBD commentaries. The addition of presentations to and from Sherman Prize winners: Drs. Gary Wu, David Rubin, and Jessica Allegretti highlighted the long-standing commitments to IBD research.
AIBD was a “soup to nuts” exploration of the newest and most clinically relevant aspects of IBD diagnostics, monitoring, treatment, and multi-specialty approaches.
There were extensive discussions on disease monitoring from a clinical, biomarker, imaging, and endoscopic perspectives:
While serologic markers were not extensively advocated at the present time, evidence is accumulating that early elevations of antibodies to microbiome (pANCA, ASCA, and others) may be predictive of development of subsequent IBD as presented by Dr. Colombel. Furthermore, while genetic profiles are not advocated in adults with IBD, certainly the identification of single gene mutations in early onset IBD provides examples of treatment-directed therapies and the potential for cure via bone marrow transplantation. Unfortunately, despite clues from genetic mutations associated with IBD risk, including TNF and IL-23 pathways, these have yet to provide utility at predicting response to the expanding availability of targeted biological therapies.
There was a lot of discussion and debate regarding the utility of fecal calprotectin. The operating characteristics were reviewed, and the intra- and inter-individual variability led some, such as Dr. Sandborn, to question the reliability of calprotectin assays, particularly in the setting of small intestinal (e.g. Crohn’s disease). Standardized protocols for obtaining calprotectin such as first stools in the morning, while challenging in the clinic setting, are likely to provide more reproducible and consistent results. The timing of biomarker measurement was also discussed and depended upon the status of the patient whether used as a baseline, for assessment of therapy or long-term monitoring.
Another area of ongoing debate regarding monitoring is the utility of chromoendoscopy. While always a lot better than standard light endoscopy, the advantages of chromo over high definition colonoscopies, which are currently the standard throughout the U.S., seems more limited. Similar to adenoma detection, the attributes of a quality surveillance examination include: high definition scopes or chromo for patients in remission with good preparations and adequate withdrawal observations. Routine “random” biopsies of normal mucosa are inefficient whereas targeted biopsies should include removal by polypectomy or EMR of all visible dyplastic/neoplastic tissue. Referral to our interventional colleagues for “en block” resection of larger neoplastic lesions was advocated by Dr. Kornbluth and others.
There were repeated discussions of positioning therapies as both clinical trial and realworld evidence continued to expand. Millie Long provided a balanced overview of interpretations of real world data and the differences between efficacy in clinical trials and effectiveness in real world use. We are enthused by the increased number of forthcoming “head to head” clinical trials as we learned from the “Varsity Trial” that compared vedolizumab to adalimumab in ulcerative colitis; a study that was a myth buster as far as expectations for lymphocyte trafficking agents. In the meantime, we need to be cautious regarding societal guidelines that are a mixture of (more limited) controlled clinical trials and expert opinion that incorporates both real world (both controlled and uncontrolled, prospective and retrospective, and observational) data, and an increasing reliance on “network meta-analyses.” The latter have been increasingly used in the absence of head to head trials but should be considered more as “hypothesis generating” than truth until conclusions are supported by prospective studies. Examples of how networks may be wrong is the lack of retrospective data supporting immunosuppressives with TNF inhibitors in controlled trials whereas prospective studies have demonstrated benefits for combination therapy. In contrast, the utility of mesalamine in Crohn’s disease patients receiving biologics has been disproven by both meta-analyses and prospective studies.
There were two sessions that stood out amongst the numerous outstanding presentations.
The first will be a definite “keeper” for future AIBD meetings: the “Editor’s picks.” Gary Lichtenstein from the American Journal of Gastro, David Rubin from Gastroenterology, Jean-Fred Colombel from Clinical Gastroenterology and Therapeutics, and Ray Cross from the IBD journal presented the highlights pertaining to IBD pathogenesis, diagnostics, therapeutics, and monitoring from the past year. Next year, we need to invite editors from Pediatric Journals to chime in and perhaps our colleagues from Gut and JCC?
The incredible session was Brennan Spiegel’s introduction to virtual reality. The lecture was a marvel in innovation of technological display as well as therapeutic potential as we observed Brennan in his own virtual reality experience as well as the potential for treatment of pain and potentially inflammation in patients. I have high expectations that virtual reality platforms will become an important tool to expand the armamentarium and efficacy of cognitive behavioral therapeutic approaches.
The keynote addresses continue to highlight current and future approaches to IBD management. I already discussed Millie Long’s review of real world data. I discussed the potential of withdrawing therapies for patients in long-term, clinical, biological, and endoscopic remissions. An absolute highlight was the comprehensive and reassuring presentation by Uma Mahadevan regarding the conclusions of the PIANO study about the safety of our current therapeutics on pregnancy outcomes and early infant development. David Rubin emphasized the importance of standardized endoscopic reporting and Ed Loftus discuss managing infectious complications in IBD therapy. Miguel Reguerio remains the master of post-operative assessment and therapeutic planning, and Maria Abreu always provides a both microscopic and telescopic perspectives of where we are heading towards employing pathogenesis into therapeutic considerations; now including genetics, environment (a lot of discussion regarding diet therapies) and evolving therapeutics.
Finally, we were prescient in designing an international discussion of COVID-19 and the impacts and implications for IBD. Prescient in the coincidence that the first, Pfizer, COVID-19 vaccine was approved the same day as the educational session. It appears that our IBD patients, for the most part, are not at particular risk of developing IBD complications (see the SECURE-IBD website presented by Michael Kappleman) although steroids and thiopurines may add a small risk. Although it is clear that COVID-19 can cause GI symptoms (loss of taste/smell, nausea, vomiting, diarrhea) that need to be distinguished from (or contribute to) IBD flares, these are usually mild and self-limited. The main risks for COVID-19-related hospitalizations and complications remain older age and other co-morbidities (obesity, heart disease, diabetes). The expert consensus was to try to reduce steroids and immunosuppressives but to continue biologic therapy for the majority of outpatients.
One of the advantages of the virtual program is the availability of viewing sessions online that were missed or wished to be seen again. We look forward to returning to Orlando for the 2021 AIBD which is certain to include both live and some virtual sessions as our ability to optimize educational programming continues to evolve.