Laura Raffals, MD, on Choosing Therapy for Crohn's After Initial Failure

Dr Raffals explains a framework for choosing a second therapy for the patient with Crohn's disease who did not respond, or lost response, to the first therapy, based on why the treatment failed.

Laura Raffals, MD, MS, is Professor of Medicine and Vice Chair of the Department of Medicine at Mayo Clinic in Rochester, MN. 

TRANSCRIPT:

Hi there. I'm Laura Raffals. I am here from Mayo Clinic. I'm a gastroenterologist specializing in IBD, and I'm here at the annual AIBD meeting today and had the opportunity to speak about how to choose your advanced therapy and somebody who's failed their first advanced therapy with a diagnosis of Crohn's disease. During this talk, I tried to emphasize that it's important to have a nice framework in your approach to choosing that second advanced therapy for your Crohn's disease patient because it's critical to try to get them on the right therapy so they have the best shot at doing well over the long term. Because we know that with every subsequent advanced therapy, the opportunity for that patient to have a good response starts to decrease. So this framework is to first understand the why is the patient failing, why did the patient fail that first advanced therapy?

So really trying to understand, did the patient have a mechanistic failure? Did they not respond to the therapy because that mechanism of action just wasn't going to work? Did they lose response to an effective therapy because they developed antibodies to that therapy, or are they not responding to that first advanced therapy just because their drug levels aren't high enough and they need to be optimized?

Once you understand the why behind that patient didn't respond to their first advanced therapy, you can move into the what is the opportunity to determine the best therapeutic strategy for that patient? Again, the why dictates the what. That's where you determine do you need to switch mechanism of action? Can you stay within class, but just switch to a different therapy within that class that would be possibly appropriate in the patient who lost response to a therapy because of antibodies to the drug? And in that situation, you would want to be sure to use an immunomodulator. And third, do you just need to optimize your treatment?

The last point of this framework, after you've gone through the why and the what, is to personalize your approach based on the patient's characteristics, their phenotype, their comorbidities, and honestly just what would be convenient for the patient or what they have access to. There are great ways to do that by understanding the mechanisms of actions and the nuances of all the therapies. But I think if you apply this framework, understanding the why, driving the what, and then personalizing your approach, you'll give your patient the best shot possible to doing well in that second advanced therapy.