Optimize or Switch Therapy? Siegel vs Regueiro Debate
For the 9th year, Drs Miguel Regueiro and Corey Siegel both claim victory in their annual debate—this time, about switching vs optimizing therapies—and remain friends.
Miguel Regueiro, MD, is professor of medicine and chair of the Digestive Disease Institute at Cleveland Clinic in Cleveland, Ohio.
Corey A. Siegel, MD, MS is the Constantine and Joyce Hampers professor of medicine at the Geisel School of Medicine at Dartmouth and director of the Center for Digestive Health at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.
TRANSCRIPT:
Dr Regueiro:
Hi, I am Miguel Regueiro, chief of the Digestive Diseases Institute at Cleveland Clinic in Cleveland, Ohio, coming to you from AIBD 2025, our annual meeting.
Dr Siegel:
And hi, I'm Corey Siegel, gastroenterologist from Dartmouth Health in Lebanon, New Hampshire, and today Miguel Regueiro and I had our ninth debate after all these years, and I have to say nine years in a row, I came away the victor. We even had ChatGPT weigh in on the topic this year, which was should you optimize nonanti-TNF therapies or switch to another drug? So if your patient's failing a nonanti-TNF biologic, should you optimize the drug, meaning giving more drug, or just switch to a different medication? And again, we put it into ChatGPT and it totally agreed with me. So once again, another win in the column for Corey.
Dr Regueiro:
Corey, I am sorry to tell you that your delusions get bigger and bigger each year. This was the ninth consecutive year that I won, the ninth consecutive year. And what I proved very effectively through a lot of data that you obviously weren't aware of, and that is very recent, is that actually using, and not optimizing, but switching to some of our newer therapies and we have so many new therapies. And what you failed to mention, Corey, is that ChatGPT claimed that optimizing therapy prior to the debate, just prior to the debate, did see some merit in that. And if you want to use the word win, which is kind of a feeble way of describing that, that's fine.
But then after the debate, which is probably more important, aside from the overwhelming number of people in the audience, which I would say was 99.9%, maybe a couple of your friends from Dartmouth didn't agree, but everybody else did. And ChatGPT clearly had me as the winner. In fact, I think our friend Dr. Long was the referee and there was a trophy that had my name on it at the end. Did you forget that part?
Dr Siegel:
Well, I think this whole thing about AI hallucinating, it's not really well formed yet, so there's still more to learn. But in all seriousness, there are arguments in both directions here. And when you have a patient sitting in front of you who had been doing well on a therapy, the example you gave was ustekinumab, and then starts breaking through therapy, we have the opportunity to say, do we give it every 6 weeks or every 4 weeks or do we move to a different therapy? And then we extrapolated that also towards the IL-23s and even vedolizumab. And there are data out there that say it's not an unreasonable thing to do to dose optimize before moving on. But we both made the point that there are other ways to think about it. And then you presented a fair argument the other way.
Dr Regueiro:
So without getting in debate mode, and I will agree that optimizing therapy is reasonable, one thing we didn't actually talk about, but it was in the chat at the end, is that now with biosimilars like ustekinumab biosimilar, it may be easy and somewhat cheap or cheaper to do that. The only other take home message I think we both agree with is that if you try to optimize the therapy to an off-label indication and the payer is not allowing you as a provider to do that and time is being wasted, don't linger on that—switch to a new therapy. Most of the new therapies now are being approved because we have so many and there will be some insurances that may give us a hard time on certain ones, but usually we can find something.
Dr Siegel:
I think that's right. I mean the message is that I think we should be giving our audience are number one, we're friends and actually agree with each other more than not on this…
Dr Regueiro:
Sometimes, except for 10 minutes at every AIBD.
Dr Siegel:
Yeah. And when you try to bias ChatGPT by feeding it fake information. But anyway, aside from that, let's first make sure we're being very clear about this. Anti-TNF therapy should be optimized before moving on and there are times not to, but most of the time, as long as there are no antibodies, there's really an opportunity to dose increase.
Dr Regueiro:
And that's why we didn't debate that because I think the data is so clear.
Dr Siegel:
However, with these other classes of medications, which we're now using very frequently, particularly the IL-23s and vedolizumab, that if your patient is doing poorly and you need to make a switch, just make a switch. Let's not wait for another few months by changing to every 4 weeks to see what happens. However, if you're kind of smoldering along and not doing terribly, but doing okay, many of our patients prefer to stay on the same medication and try it a little bit longer and it's not unreasonable to make a switch and see how they do.
Dr Regueiro:
And the only other final thing along those lines that I completely agree, and I think we actually practice more similarly than we debate, is that with the IL-23s and with the JAK inhibitors, we do have different doses. So if a patient is on a lower dose and these are on label, these are approved doses on a lower dose and they're not actually having the response we want, you can simply optimize to a higher dose, which is on label. And that's not usually as difficult as going off-label.
Dr Siegel:
No, agree.
Dr Regueiro:
So any thoughts on our debate in 2026? Not necessarily the topic, but any teasers for the audience?
Dr Siegel:
I think we should debate if Chat GPT has any merit to use in medicine, it would be number one. I've learned today that I don't trust it anymore. And number two, that you're a difficult debate opponent. And number three, I think there are unfortunately plenty of controversies in our field that we will find a good topic to argue over.
Dr Regueiro:
And I'll just keep it simple. So the 10th year in a row, Miguel Regueiro will be the winner in 2026. And it doesn't matter what the topic, I'll let you choose again this year as you have done in so many years, but continue to lose.
Dr Siegel:
And my final word, I guess, is that Chat GPT hallucinates. And so does Dr. Regueiro.
Dr Regueiro:
And we could keep going on.
