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Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. Joining me today, we have a panel with Dr. Daniel Chu. He's an associate professor and colorectal surgeon and Dr. Kirk Russ. He's an assistant professor, a gastroenterologist and a clinical educator with primary focus in inflammatory bowel disease. They're both at UAB Medicine and they're here to offer an update on Crohn's disease and colitis. Gentlemen, thank you so much for being with us today, Dr. Russ, I'd like to start with you. Can you start a little bit about Crohn's and colitis today? What you've been seeing in the trends? The prevalence? Tell us a little bit about it.

Dr. Kirk Russ: Sure. And thanks for having me, Melanie. So both ulcerative colitis and Crohn's disease have a similar prevalence and it's anywhere from probably close to 200 per 100,000. People in the us for both diseases and there's estimated to be over, I think, around 3 million patients living with inflammatory bowel disease in the us alone. As far as trends go, we historically have seen things, continue to rise.

Some more recent data would suggest that maybe it's plateauing in the Western world, but we still are seeing rising incidences of both ulcerative CLOs and Crohn's disease in previous years that didn't have very much incidents like south America the Middle East Asia. So we're definitely still seeing rising incidence there. And I think Dan could probably chime in on this, but we there's no shortage of patients here. We see a whole lot of patients with inflammatory bowel disease.

Dr. Daniel Chu: Yeah, so I absolutely agree with everything that Dr. Russ had said about the incidents and the prevalence. Definitely over 3 million people in the United States growing across the world. And what's interesting too, within the United States that I think we're seeing is that there's certain sort of racial and ethnic groups where we're also seeing more inflammatory bowel disease.

This is one of those diseases that classically, we thought it was isolated to certain populations in Western Europe and in the United States. But we're seeing the incidents really grow in populations that previously we really didn't think would have a lot of, IBD populations, Asian Americans, African Americans, Latino Americans. So we're seeing it in these groups which is important to point out.

Melanie Cole, MS (Host): Well, it certainly is. And we're gonna get into some theories that you both might have, but before we do Dr. Chu, how has treatment and the thoughts of treatment evolved over the last decade or so, tell us a little bit about what we used to think, but what's different and any exciting updates that you have to share with us?

Dr. Daniel Chu: Yeah. So I'll be reprised some perspectives just from a colorectal surgeons point of view. Crohn's and ulcerative colitis has always been a very complicated disease. It's not just medical management of inflammatory bowel disease, but also surgical management. And so I think the treatment strategy has certainly continued to grow. As people have realized it is entirely multidisciplinary. It is very much a team approach. And I think the more coordinated the team can be the better the care.

And what I mean by that is this management requires, I think a IBD gastroenterologist like Dr. Russ. It requires certainly Al input from people like myself, but it also requires nutritionalists and pharmacists, even psychologists. It requires a whole group of people with multiple expertise to really handle and treat IBD well.

Dr. Kirk Russ: Yeah. And I'd just like to add there on the medication front. I think we've really come a long way since infliximab or rheumatoid was approved in 1998. And we're well into the biologic and now small molecule therapy era. And we've really shifted from focusing mainly on patient symptoms and improving those to now more stringent. In points like endoscopic or mucosal healing and now even considering is histologic healing an endpoint that we're shooting for. So we've come a long way and our goals are now shifting more towards trying to change a patient's disease course and really prevent long term.

Structural damage to the bowels and long term complications of just prolonged inflammation and the toll that can take on someone. So, it's an exciting time, honestly, but we're continuing to see newer and newer therapies and more and more treatment options.

Dr. Daniel Chu: And just to go off of that from a surgery standpoint too, I think, we piggyback off of much of what happens with medical management. Ideally that is the primary goal is medical management to quiet down the inflammation. And by the time patients get to surgery we are sort of an adjunct, I would say and to help manage those situations where the medications can't help patients anymore.

Dr. Kirk Russ: Yeah, absolutely. I mean, I think surgery shouldn't be treated as a treatment of last resort. It is actually sometimes the treatment patients need. So we appreciate the assistance of our colorectal surgery colleagues like Dr. Chu.

Melanie Cole, MS (Host): Well, I think it's so important when you discuss this multidisciplinary approach and Dr. Russ, what are some of the challenges that you've found that you'd like to share with other providers when deciding on these therapies, as you mentioned, their biologics? There's so many new things in the pipeline, you have so much more in your toolbox that how are you deciding based on how the patient presents and their family history, on these therapies and tell us some of the challenges, how you've overcome those?

Dr. Kirk Russ: All right. That's sort of a loaded question, Melanie, but I will try to unpack it. There's just a lot of factors that come into play. So you really have to start with, one thing would just be which disease is this ulcer colitis first Crohn's disease. You have to take into count the severity of the disease. Which may be what it looks like on a colonoscopy and also maybe how labs and other tests look that factor in you have to take into account patient preferences. Do they prefer an injection over an infusion? There's things like extraintestinal manifestations that if they're present may kind of help determine which is the best therapy for them.

And then also their comorbidities they have a history of cancer, they have another condition that might affect. The treatment choice, something like psoriasis, for which we have medicines like ustekinumab that actually treat both psoriasis and ulcerative colitis and Crohn's disease. So there's a lot of factors that come into play. And I think you have to sort of see a patient, do your evaluation, talk with them and find out their preferences and usually after that you're able t o guide yourself at least into a couple potential options and then talk to 'em about the risk and benefits.

And I think it it is only getting more complicated as we get newer and newer therapies, some of which are in a similar category to an existing therapy. So now you have multiple treatment options that essentially target the same target in the immune system, in the immune response in inflammatory bowel disease. And how do you decide between those? So we're still fortunately getting more and more head to head trials that will help us hopefully position these therapies. So still a lot to learn, but we've come a long way. And I think we have some kind of basic positioning at the current state of things.

Melanie Cole, MS (Host): Dr. Russ sticking with you for just a minute, as you talk about all of these various therapies, and obviously as you said, it depends on the diagnosis, but can you spend a minute and tell us a little bit about a holistic model of care that recognizes? Because Dr. Chu mentioned it just briefly, but the complexity of these inflammatory bowel diseases, the evolving role of diet, as we're learning it in the pathogenesis and treatment of these diseases, the role that stress. I mean, now we're learning more and more about this connection and even the brain and gut connection. Can you tell us what we've learned, what you know about this, or want to share with other providers?

Dr. Kirk Russ: Yeah, I think that's a great topic. I think we're learning more. There's still a lot to learn, I think, in these areas, but it really is a team sport, and we really need a multidisciplinary approach. And these patients have higher instances of depression and anxiety and sort of psychosocial needs that having a psychologist or a psychiatrist as part of the team is really crucial. I think we definitely know that diet can help with symptom control and in the pediatric population, they will actually use dietary modification instead of using steroids to treat symptoms.

And there's interestingly a subset of patients that you can actually see their inflammatory markers improve by making certain dietary changes. So we definitely think diet is playing a role in symptoms and also. Potentially the development of the disease as it alters the microbiome and the immune response to the microbiome. So it's very important thing. And I think a nutritionist is really an essential part of the team. And we're fortunate to have a couple here at UAB that, we consult with frequently.

So I think you have to take into account all those things. And that's the diet is probably the most common question we get in clinic is what can I do with my diet? Because it's one of the few things in this situation. When you're you have a diagnosis of inflammatory bowel disease, everything's out of your control, but you can control your diet. And so I think that's definitely an essential part of the team. And I think, we're starting to pay more attention to some of the long term quality of life indicators and symptoms that people deal with.

Because that sometimes get overlooked issues like incontinence and urgency and certain symptoms that just haven't been at the forefront of the way we evaluate things. And just the toll that takes on people. I mean, patients can actually get. Post traumatic stress disorder from just their experience with their Crohn's disease or ulcer colitis. So it's a complex illness and the gut brain access is very much real and diet is definitely gonna be a helpful part of treatment going forward I think.

Melanie Cole, MS (Host): Dr. Chu, what would you like to add to that? And while you're doing that, tell us a little bit about anything exciting in your fields far as surgical interventions or how your outcomes have been. Tell us a little bit about your role in this?

Dr. Daniel Chu: Yeah. So, I agree with everything. Dr. Russ has said. The management of IBD is very much a team approach. There's just so many pieces to the puzzle here. An d I gotta stress too, that there's no. One answer one way to do things there's oftentimes two or three choices that need to be made. And so it's incredibly important for patients and their providers to sit together in the same room to sort of make those decisions so that everyone is at least on the same page, because certainly there are no freebies in anything, every choice, every medication, every surgery has its risk to acknowledge.

I think, in the surgery world in terms of new things, the operations, I gotta say still are fundamentally the same, the way we do it though, I think is a little bit different. What I mean by that is we have always known that minimally invasive approaches to surgery is a good thing. And we have more tools now that we can use to perform minimally invasive surgery. So meaning we can do it with laparoscopic instruments, we can do it with hand assist. And we oftentimes often use the robot too, which I'm sure many patients and providers have heard about.

So those are just the different ways that we can do the surgery in a better way. I think the other thing that we do now for surger. Is we focus on the recovery itself, right? The operation itself is oftentimes the easiest part, it's really what happens after the surgery. That can be really challenging how patients recover. And so that's an area that in the surgery world, we do a lot of things called enhanced recovery programs now for surgical patients, that really helps patients just recover better and faster. And these elements of the programs are nothing fancy.

They're simply best evidence practices that are already out there that people are already doing around the world, but it just organizes it and delivers it all together consistently to every patient in the right way at the right time. So I think those are some of the biggest things that are happening within the surgery world. I think IBD in particular is particularly challenging from operation standpoint because of the inflammation, because of the chronicity, because oftentimes there's redo operations. But I think, we've gotten better at how we do it and how we recover patients. And I think that contributes to better outcomes now and the IBD surgery world.

Melanie Cole, MS (Host): Very well said, Dr. Chu, I'd like to give you each a final thought what you would like to share with other providers. So, Dr. Russ, starting with you, we're talking about referral here. So when do you want other providers and community physicians to know and feel that's the important time to refer to the experts at UAB Medicine in the cases of inflammatory bowel disease?

Dr. Kirk Russ: Yeah, I think that's a great question. I think definitely anyone that is medically refractory. So if someone's failed a couple different treatments or biologics and they still have active disease and you're not sure where to go next with their therapy. I think that's always a reasonable time to refer for a second opinion. I think in Dr. Chu's realm referral for colorectal surgery expertise is also a great reason to refer patients here. Your community surgeon may not have as much colorectal experience and really, especially for these inflammatory bowel disease.

Patients having someone that has the expertise, the experience operating hundreds, if not thousands of Crohn's disease or ulcer colitis patients is really paramount and associated with better outcomes. So I think those are two reasons off the top of my head. The other common ones, I would say that we get would be things like unique situations, someone with cancer and active inflammatory bowel disease. And for specialty procedures, things like chrohn endoscopy, when we're looking for precancerous changes in the colon. If those are identified in the community, sometimes we'll get referrals for that. So there's a lot of reasons, but those would probably be the most common.

Melanie Cole, MS (Host): Dr. Chu, last word to you. And so appreciate that you brought up the importance of eras and you and I have done a podcast on that before. So listeners, you can look that up anytime you want, but I'd like you to speak just about anything exciting that you see coming down the pipeline, any research, promising therapies, anything that you would like other providers to know that you are all doing there at UAB Medicine.

Dr. Daniel Chu: Yeah, that's a great question. And Dr. Russ, we know more, so about the newer medical therapies that are coming online since I do defer to my gastroenterologist colleagues for their expertise on sort of the newest biologics and the newest biosimilars that are coming out. I do think within that area of research and treatment for IBD I think a lot of work now is focused on the diet piece that Dr. Russ had talked about in terms of what kind of diets might be the quote unquote, best diet for different situations.

I think from a medication standpoint, I know there's a lot of new biologics. New ways to deliver biologics, whether orally versus the kind of the usual IV infusion. And the biosimilars in terms of which combination of those drugs might be the way to treat a patient depending on how severe the IBD is. I think in the area of research that is still active too, that we still don't, I think have good answers to is within the microbiome itself. Certainly that's a buzzword that you'll see a lot and hear a lot about the microbiome in your body and how that relates to diseases like IBD.

And I think there certainly is a relationship. I don't think their relationship is understood yet, which is why there's so much research in this area. But the idea is that we can maybe look at certain profiles of microbiomes that can determine how severe or how a certain case of IBD might respond to treatment and be able to tailor. Our treatment for IBD in a much more refined and purposeful way. So those think those are some areas that are out there. and I'd be curious to hear From Dr. Russ, whether there's any other areas that he's seen from his side of the medical world.

Dr. Kirk Russ: Yeah. I mean, I think you did a great job there, Dan. I think you hit a lot of the high points, I think you're right dietary modification, modulation of the microbiome, how do we do that or accomplish that? I think those are all exciting things. And I do think combination therapy. We have some emerging evidence and even at clinical trials one of which we're gonna be participating in that it's looking at combining these biologic and small molecule therapies to get better response rates, because the reality is there is a ceiling, there's a therapeutic ceiling with a lot of these drugs. And we just need to do better. They don't work for everybody.

And I guess maybe one, one or two more other things, one would be personalization or personalized medicine. Just being able to determine which drug is the best drug for an individual patient. We're not there yet, but I think we're making progress and I think we will get there probably within the next five to 10 years. And I guess lastly, and this is maybe something you could comment on Dan too, is maybe an encouraging therapy for perianal disease, which can be incredibly difficult to treat would be stem cell injections into the fistula tracks. And so that has shown some promising results I know.

Dr. Daniel Chu: Yeah. Thanks for bringing that up Dr. Russ. So what Dr. Russ is talking about is this idea of Crohn's disease in anorectal fistula, which can happen in a significant portion of Crohn's patients. And these fistulas are tunnels that go from the inside of the rectum and anus out to the skin and can be notoriously difficult to close and to handle. And so there's been a lot of new research focused on finding new ways to close those fistula tracts using stem cells from patients and essentially it's stem cells that are harvested, they're grown.

And then they're, re-injected into that tract. And there's definitely been some good signals that this can have some benefit. I think just those trials that need to be done to really. Show exactly how much of a benefit it is. But that being said, there's great potential. And certainly the principles of that technique are good and valid. So I think there's more to come from that, but that definitely is another area of innovation within IBD treatment.

Melanie Cole, MS (Host): What an exciting time to be in your field gentleman. So many emerging therapies. And thank you so much for sharing your expertise today with other providers that was just excellent. And so informative, a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician.

That concludes this episode of UAB MedCast and for the updates on the latest medical advancements, breakthroughs and research, just like you heard here, please follow us on your social channels. I'm Melanie Cole.