Two themes permeated the 20th anniversary year for Advances in IBD. The first was the evolution to personalized medicine and the second was an expansion of the concept of an IBD Medical Home and the incorporation of virtual monitoring and telehealth.
The concept of personalized medicine continues to evolve in a variety of contexts. Essentially, personalized medicine is an optimized approach to the best medicine at the best time for an individual patient. The main session focused on our past 20 years with a glimpse toward the future and began with Dr. Abreu’s insightful updates on pathogenesis with foci on the potential genetic, serologic, and environmental factors with increasing clinical applications (e.g., genetic polymorphisms impacting drug metabolism, serologic predictors of disease evolution, and modifiable exposures including food additives.) Throughout the conference, Dr. Abreu referred to factors that could contribute to population and ethnic factors impacting Latinx immigrants. The concepts were advanced by Dr. Ed Loftus’ review of current positioning which is, unfortunately, not very personalized beyond individual therapeutic monitoring, and Dr. Marla Dubinsky’s lecture on personalized medicine and predictive factors to improve outcome including therapeutic monitoring. I concluded with a 20+ year perspective on how clinical pharmacology has improved individual outcomes based on both genetic polymorphisms (sulfasalazine, thiopurines) and how to improve outcomes with biologic therapies as we move toward additional novel mechanisms (JAK and sphingosine 1 phosphate modulation). I also noted the potential to combine mechanisms of action to improve the “therapeutic ceiling” we are confronted with based on individual outcomes with newer, advanced therapies including biologics and small molecule. Ultimately, Dr. Britta Segmund, provided a European perspective from ECCO regarding approaching IBD based on anatomic distribution presented as the Richard McDermott honorary lecture.
The concepts of medical homes for IBD patients and the expanding utilities of remote monitoring and virtual visits were the other futuristic theme(s) throughout the meeting. The COVID-19 pandemic unleashed the imperative for telehealth in the absence of face to face encounters. The proportions of telehealth visits continue to modulate according to locations, local restrictions, and technology. For a short time, telehealth was necessary during COVID-19 “lockdowns” but has persisted in a variety of situations. Clearly, patients favor virtual visits from a convenience standpoint although access can be quite variable and it is unclear if underserved populations have an equitable access to virtual technologies. Similarly, elderly populations may not have the technical savvy to maneuver through electronic communications.
I debated Dr. Ray Cross regarding the virtues of telehealth but we both emphasized the positive (patient preference, potential cost savings, etc) as well as the clinical (no physical exam, challenges to maintain health maintenance such as vaccines and laboratory monitoring outside of system EHR, technical access and privacy issues) challenges for virtual encounters. A number of issues and questions remain as to how this technology, that is here to stay in many aspects, can be standardized, optimized, and evaluated for clinical and economic outcomes. Speaking toward the future, both Dr. David Rubin and Dr. Miguel Regueiro discussed aspects of expanding home monitoring technologies to improve patient outcomes. While it is obvious that a “medical home” will not be feasible for many IBD practices across the U.S. and outside the U.S., centers that have established coordinated, multi-specialty service lines including gastroenterologists, colorectal surgery, advanced practice clinicians, patient navigators, specialized nurses, specialty pharmacies, social workers, behavioral psychologists, and dietitians can provide high level, comprehensive, longitudinal care that will be supplemented by evolving technologies to monitor patient's pulse, blood pressure, sleep patterns, heart rate variability, clinical symptom status, and, eventually, laboratory monitoring. A variety of platforms for medical specialty homes, virtual monitoring, and incorporation into EHRs will be a substantial component of our future clinical care and further optimization of individual and population monitoring through the chronic care of IBD patients.
Dr. Hanauer reports consulting fees from Abbvie, Allergan, Amgen, BMS, Boerhinger-Ingelheim, Arena, GSK, Janssen, Lilly, Merck, Covartis, Pfizer, Progenity, Protagonist, Prometheus, Salix, Seres Therapeutics, Takeda, and VHsquared. He reports eees for participation in review activities from Arena, Boehringer-Ingelheim, BMS, Gossamer, Prometheus, and Protagonist. He also reports payment for lectures from Abbvie, BMS, Janssen, Pfizer, and Takeda.
Illustration by April Brust