Exabis Library

What is the optimal timing and methods for monitoring?

Educational objectives:
1. To understand the importance of disease monitoring in a treat-to-target strategy
2. To understand the difference between a treatment target and an instrument of tight disease control
3. To understand the need for a non invasive patient-friendly disease monitoring
4. To emphasize a proposal for a structured time-bound monitoring

 Disease monitoring is the corner-stone of a treat-to-target strategy. The definition of the treatment target is linked to our understanding of the disease process and the availability of markers to assess the disease process. Beside the target, we may define several steps to reach the target which are associated with specific tools and markers. Monitoring tools are not unique and must be articulated in a time-bound manner to allow an optimal disease control aiming at alleviating the symptoms and avoiding disease progression. In particular is a full endoscopic healing is currently the most widely accepted objective, intermediate steps may include symptomatic improvement and biomarkers improvement and normalization.

Up to 50% of Crohn’s patients develop intestinal strictures during their disease course. In general, predominant-inflammatory strictures are likely to benefit from anti-inflammatory medical therapy, whereas predominant-fibrotic strictures often require endoscopical/surgical approach. However, rarely is a stricture merely inflammatory or fibrotic; they are typically characterised by a mixture of inflammation, muscular hypertrophy, collagen disposition and fibrosis. Cross-sectional imaging techniques allow full-thickness evaluation of the bowel wall, of which IUS is non-invasive, cost-effective and can be used in the point-of-care setting, which makes is an attractive tool for monitoring.
The aim of the talk is to review the challenges of distinguishing inflammatory and non-inflammation strictures on conventional B-mode IUS and on advanced US modalities, such as CEUS and elastography.  

To understand imaging findigs of Fibrosis on cross sectional imaging with emphasis on MR-E 
To review litterature on MR-E and fibrosis
To have an overview over new imaging tools of Fibrosis (delayed enhancement, DWI, IVIM, Magnetization trasfert, Motility study).

Educational Objectives:
1. To appreciate the strong impact of the diet on gut microbial community structure and function
2. To understand the role of the diet in the pathogenesis of experimental gut inflammation
3. To review a role of the diet on the development and course of human inflammatory bowel diseases

1) Overview of the aetiology of IBD
2) Discussion of the impact of the environment on disease onset, course and response to therapy
3) Focus on the emerging evidence of a role of diet on disease onset from animal models, epidemiology and human studies
4) Discussion of the potential to modify the environment as a preventative strategy / therapy

Learning Objectives:
1. Screening before immunosuppression and immunisation
2. Indications for biological therapy
3. Evaluation of response

IBD patients are eligible to treatment with biologic agents if they have failed or cannot tolerate conventional treatment with corticosteroids and/or immunomodulators (IMMs) or are corticosteroid dependent. Early introduction of biologic therapy is also recommended for patients who at diagnosis have clinical features that predict a disabling course of disease. Ideally, patients should be screened for infectious diseases, malignancies, and complete all essential vaccinations before starting any therapy. Selecting the best biologic amongst the currently available different classes, depends on several patient- and disease-related parameters, such as age, disease activity, comorbidities, and the overall burden of disease. As for any therapy, it is important to define short-, medium- and long-term goals, monitor the progress of disease and adapt treatment accordingly (treat to target).

The first biologic is the best shot. Thus, it is key to adapt dosing to disease activity to avoid primary non-response or partial response and thus achieve a better long-term response. Co-treatment with an IMM may influence the pharmacokinetics in particular of anti-TNF and prevent early development of anti-drug antibodies ADA). Once clinical remission has been achieved, patients should be closely followed by monitoring clinical activity (patient reported outcomes), biomarkers (serum CRP, faecal calprotectin), imaging (US, MRE), endoscopy and/or histology. Treatment optimization in case patient loses response can be achieved either empirically (Standard of Care) by increasing the dose of the biologic or halving the administration interval, or both, or by adding an IMM, or by therapeutic drug monitoring (TDM), i.e., by measuring drug levels and ADA. Pro-active TDM has not been proven superior to reactive TDM, still, it serves to discriminate between pharmacokinetic and pharmacodynamic failure of treatment. However, proactive TDM is increasingly used to achieve clinical response and/or remission during induction, to de-escalate, or stop biologic therapy.

4. Screening before immunosuppression and immunisation
5. Indications for biological therapy
6. Evaluation of response