When Perfect Is the Enemy of Good: Results of a RAND Appropriateness Panel on Treat to Target in Asymptomatic Inflammatory Bowel Disease.

Autor:	Systrom HK; Dartmouth Hitchcock Medical Center, Division of Gastroenterology and Hepatology, Lebanon, New Hampshire USA., Rai V; Yale School of Medicine, New Haven, Connecticut USA., Singh S; University of California San Diego, Division of Gastroenterology, San Diego, California USA., Baidoo L; University of Tennessee College of Medicine, Inflammatory Bowel Disease Center, Memphis, Tennessee USA., Cheifetz AS; Beth Israel Deaconess Medical Center, Inflammatory Bowel Disease Center, Boston, Massachusetts, USA., Devlin SM; University of Calgary, Inflammatory Bowel Disease Centre, Calgary, Alberta, Canada., Gecse KB; Amsterdam University Medical Center, Gastroenterology, Amsterdam, Netherlands., Irving PM; Guy's and St. Thomas' Hospitals, Gastroenterology, London, United Kingdom., Kaplan GG; University of Calgary, Inflammatory Bowel Disease Centre, Calgary, Alberta, Canada., Kozuch PL; Jefferson University, Division of Gastroenterology, Philadelphia, Pennsylvania, US., Ullman T; Montefiore Medical Center, Division of Gastroenterology, Bronx, New York, USA., Sparrow MP; The Alfred Hospital, IBD Unit, Melbourne, Victoria, Australia., Melmed GY; Cedars-Sinai Medical Center, Inflammatory Bowel Disease Center, Los Angeles, California USA ., Siegel CA; Dartmouth Hitchcock Medical Center, Division of Gastroenterology and Hepatology, Lebanon, New Hampshire USA.
Jazyk:	angličtina
Zdroj:	The American journal of gastroenterology [Am J Gastroenterol] 2024 Jul 15. Date of Electronic Publication: 2024 Jul 15.
DOI:	10.14309/ajg.0000000000002964
Abstrakt:	Background: A treat-to-target strategy for inflammatory bowel disease (IBD) recommends iterative treatment adjustments to achieve clinical and endoscopic remission. In asymptomatic patients with ongoing endoscopic activity, the risk/benefit balance of this approach is unclear, particularly with prior exposure to advanced therapies. Methods: Using the RAND/University of California Los Angeles Appropriateness Method, 9 IBD specialists rated appropriateness of changing therapy in 126 scenarios of asymptomatic patients with ulcerative colitis and Crohn's disease and active endoscopic disease. Disease extent and behavior, prior treatment, prior complications, and recent disease progression were considered, as were factors that might influence decision-making, including age and pregnancy. Ratings were collected through anonymous survey, discussed at an in-person meeting, and finalized in a second anonymous survey. Results: Panelists rated change in therapy as appropriate (i.e., expected benefit sufficiently outweighs potential harms from continuing therapy) in 96/126 scenarios, generally in patients with progressive, complicated, and/or extensive disease, while changing therapy was rated uncertain in 27 scenarios of mild and/or stable disease. Changing therapy was rated inappropriate in ulcerative colitis patients with mild and stable disease previously exposed to ≥3 therapies or with improved endoscopic activity, and in Crohn's disease patients with only scattered aphthous ulcers. The validated threshold for disagreement was not crossed for any scenario. Patient age older than 65 years and a plan for pregnancy in the next year might influence decision-making in some settings. Discussion: Appropriateness ratings can help guide clinical decision-making about changing therapy to achieve endoscopic remission in asymptomatic patients with IBD until data from ongoing randomized studies are available. (Copyright © 2024 by The American College of Gastroenterology.)
Databáze:	MEDLINE
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