Personalizing IBD Therapy: The Asian Perspective

Abstract

Background: All patients with inflammatory bowel disease (IBD) share common therapeutic goals, such as complete mucosal healing and improved long-term outcomes (e.g., reduction in hospitalization, surgery and mortality). However, because IBD patients have diverse features in terms of severity, phenotypes, clinical courses and responses to therapy, therapeutic options for achieving these goals differ among patients, from no therapy to early introduction of combination therapy with anti-TNF and immunosuppressive agents. Key Messages: By personalizing IBD therapy, we may be able to maximize management efficacy, minimize the risk of adverse events and ultimately decrease costs. The initial steps of personalized therapy involve the selection of the right patients by predicting the clinical course of IBD and the subsequent selection of the right therapy by predicting the response to therapy. The next step of personalized therapy involves the adjustment of therapy through therapeutic response evaluation and therapeutic drug monitoring. Notably, current recommendations on personalized IBD therapy are mainly based on results derived from Western populations. However, Asian patients with IBD are different from Western patients in many respects, including clinical characteristics, therapeutic response and prognosis, probably due to differences in environmental and genetic backgrounds. In addition, the healthcare systems and sociocultural backgrounds of Asian countries are not the same as those of Western countries. Therefore, personalized IBD therapy for Asians may differ from that for Westerners in some aspects. Conclusions: This review discusses the current progress of personalized IBD therapy and its application from the Asian perspective.

Early anti-TNF/immunomodulator therapy is associated with better long-term clinical outcomes in Asian patients with Crohn’s disease with poor prognostic factors

“…As treatment strategies must be individualized, depending on each patient’s comorbidities and prognosis [20], medications should be chosen based on a balance between their efficacy and safety [34]. Selected patients may require early intensive therapy to prevent disease progression and poor outcomes, whereas others may live with well-controlled disease activity without early intensive therapy [35, 36].…”

“…Conventional step-up therapy is being adopted to treat IBD patients in Korea, and anti-TNFs are indicated and reimbursed by the government for use in patients with moderate to severe disease activity after failing conventional medications [20, 43]. Compared with patients in the late therapy group, those in the early anti-TNF/IM groups may have required more intensive treatment after failure of conventional medications during the early course of disease.…”

“…CD was definitively diagnosed based on patients’ clinical features, laboratory findings, endoscopic features, radiologic features, histologic findings, imaging test results, and surgical findings [22]. Patients were included if they had at least two of the following risk factors for progression; diagnosis at age <40 years, need for systemic corticosteroids <3 months after diagnosis, and perianal fistula at diagnosis [19, 20, 23]. Patients followed up for <36 months after diagnosis, and those with insufficient medical records before referrals, were excluded, as were patients who were never treated with an anti-TNF/IM or who had evidence of stricturing and/or penetrating complications before or at diagnosis of CD (Fig 1).…”

“…It is therefore necessary to select patients who would benefit from these more potent agents, both in controlling disease activity and preventing disease progression [17, 18]. Several factors are associated with poor prognosis in patients with CD, including young age at diagnosis, perianal disease at diagnosis, upper gastrointestinal tract involvement, early need for systemic corticosteroids, and smoking [19, 20]. These factors can be used to select patients requiring treatment with anti-TNFs, even if these patients show mild disease activity at diagnosis.…”

Biomarkers Predictive of Response to Thiopurine Therapy in Inflammatory Bowel Disease

“…The reader is directed to some excellent reviews on the use of genetics and immunology in predicting treatment responses and disease course (1), including the use of gene expression signatures from involved tissue and genetic variability at non-IBD susceptibility loci, for example, apoptosisrelated genes for T cells (86,87). The early detection of treatment failure and prediction of treatment responses are important in maximizing efficiency, and minimizing cost and side effects, and can be considered to be the first step in achieving the goal of individualized IBD management (88). The low population response rate of most treatment regimens for IBD lends itself to the emerging paradigm of CD and UC having many subtypes (89), therefore, increasing the importance of tailoring treatment to the individual.…”