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Pers-IBD-AGW24

Peter Higgins
September 14, 2024
310

 Pers-IBD-AGW24

Personalizing IBD Therapy talk at Australian GI Week in Sep 2024

Peter Higgins

September 14, 2024
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  1. MICHIGAN IBD Personalising Therapy in IBD Peter D.R. Higgins Timothy

    T Nostrant Endowed Professor of Gastroenterology University of Michigan Slides: https://speakerdeck.com/higgi13425/pers-ibd-agw24
  2. MICHIGAN IBD MICHIGAN IBD Today's Agenda • Access and Preferences

    • The Promise of Multi-Omics • Hints and Shadows • Lasting Steroid Effects • Sequencing, Durability, and Timing of Therapy
  3. MICHIGAN IBD MICHIGAN IBD Access to Medicines • Cost is

    a major factor in patient access • Different in every country • The US has over 1,160 private health insurance companies • Each offers multiple plans • It can be cost-effective to pay for patients to leave the US for meds • Michiganders can drive to Windsor, Ontario for a 90-day supply • Utah governmental employees flown q3m to Tijuana, Mexico for biologics • If a patient can't access the drug, it won't work.
  4. MICHIGAN IBD MICHIGAN IBD Patient Preferences • Patient preferences (tablet,

    SQ, infusion) matter • Patents often default to safety, especially early in disease • Often choose ineffective ‘natural therapy' in absence of good advice • Patients are often innumerate • Have a hard time weighing harms of disease vs risk of side effects • Often don’t understand the irreversibility of bowel damage • If the patient can't or won't take the medicine, it won't work • Select a therapy that the patient is willing to invest time in Nova Scotia Collaborative IBD Program
  5. MICHIGAN IBD MICHIGAN IBD Multi-Omics and Type 1 Error •

    If you test thousands of • Proteins • Transcripts • Gut bacteria • Metabolic components of stool • You are likely to find something significantly different between any two groups • Responders to anti-TNF, anti-IL23, or Vedo vs. nonresponders • But is it actually predictive, and generalizable to other populations? • Unfortunately, usually not
  6. MICHIGAN IBD MICHIGAN IBD A Few Examples • Metabolism of

    5-ASA by the gut microbiome in UC predicts who will be non-responders! (1) • Gut microbiome predicts response to Ustekinumab! (2) • Metabolome and microbiome predict Vedo and Uste responses! (2-5) • PREDICT panel of biomarkers will predict who needs early IFX! (6) • It can seem like we are on the brink of being able to pick the most effective / timely therapy for each IBD patient… (1) Mehta RS, et al., Nat Med 2023;29:700–9. (2) Doherty, et al. mBio 2018; 9: e02120-17.; (3) Ananthakrishnan, Cell Host Microbe 2017; 21:603. (4) Lee, Cell Host Mictrobe 2021; 29: 1294-1304., (5) Ding, NS, JCC 2020; 14: 1090-1102. (6) Biasci, et al. Gut. 2019; 68: 1386-1395.
  7. MICHIGAN IBD MICHIGAN IBD But Then the Debunking Occurs •

    Often sample sizes are small, & the # of predictors tested is large • Statistical rule of thumb: 10-20 outcomes (remission) for each predictor. • Rinse Weersma lab leading the way • 5-ASA acetyltransferase story did not generalize to 1000 Dutch IBD pts. • Microbiome/metabolome story for Uste and Vedo did not generalize • PREDICT Authors debunked their own panel of biomarkers • Did show early (w/in 14d of Dx) IFX seems to help everyone with CD Karmi, et al. https://doi.org/10.1136/gutjnl-2024-332205 Prins, FM, et al. Gut Microbes, 16, https://doi.org/10.1080/19490976.2024.2391505 Noor, et al. Lancet G & H. 2024; 9: 415-427.
  8. MICHIGAN IBD MICHIGAN IBD Multi-Omics is Hard • Very expensive,

    shiny new object for funding agencies • Sample sizes are small ($$$$), predictor number is large. • Lots of mis-application of ML and AI to tiny sample sizes • We must remain skeptical and repeatedly test the generalizability of predictive findings • We should expect that most of these will wash out.
  9. MICHIGAN IBD MICHIGAN IBD Is Immune "polarization" a thing? •

    The patient who develops psoriasiform lesions on an anti-TNF is uncommon and different • Similar response if you try a 2nd anti-TNF • But this patient switched to an anti-IL12/23 or anti-IL23 does VERY well • By blocking TNF, are we selecting for anti-TNF resistance? • Gut microbes stimulating gut immune system, one pathway is blocked • 'Nature finds another way' – the IL-23 pathway? • Does anti-TNF therapy prime (some) patients to respond to anti-IL23?
  10. MICHIGAN IBD MICHIGAN IBD Data on Autoimmune Skin Disease (ASD)

    Inflamm Bowel Dis. 2022 Jun 3;28(6):895-904. doi: 10.1093 Endoscopic Changes Crohn's patients treated with ustekinumab with Autoimmune Skin Disease (ASD) - had more endoscopic improvement - had more radiologic improvement - had more pathologic improvement - greater downslope in FCP (61% reduction vs 11%, p =0.03) vs. Crohn's patients without ASD
  11. MICHIGAN IBD MICHIGAN IBD Does anti-TNF therapy prime (some) patients

    to respond to anti-IL23? • Does the reverse occur? Does anti-IL-23 mechanistic failure (good drug level, active inflammation) prime patients to respond to anti-TNF? Schmitt,H, Atreya, R, et al. Gut 2019;68:814-828. Some patients (green) who on anti-TNF (left) Have little change in their gut T cells, Intestinal biopsies look the same – they respond Others (pink) on anti-TNF dramatically increase the number of T cells (CD4) with both TNF and IL23 receptors. These people tend to FAIL anti-TNF. and tend to respond to 2nd line anti-IL23
  12. MICHIGAN IBD Can We Use Polarization to Help Patients? Anti-TNF

    Anti-IL23 Alternate when fail due to polarization Use a bivalent antibody, Or combine two biosimilars
  13. MICHIGAN IBD Durable Effects of Steroids? Do Steroids Make IBD

    Patients More Refractory to Other Therapies?
  14. MICHIGAN IBD MICHIGAN IBD Durable Steroid Effects? Gastro 2023; 165:

    963-975 Ann Pharmacother. 2020;54:729-741. CS-free Rem in Uste, Vedo, IFX 2x ↓ in 3rd Q 10x ↓ in 4th Q Quartiles of intra-abdominal Fat mass GLP1-RA: IBD Rx Potentiator?
  15. MICHIGAN IBD MICHIGAN IBD Durability of Biologics in IBD in

    Australia • The best biologic is the 1st one • Usually get 2 years or more of benefit • Rarely > 7 years of benefit • Lose durability with 2nd ~13 months • Lose more with 3rd line ~ 10 months • Medians total ~ 4.5y from 1st & 2nd & 3rd line • The biologic burn rate is spectacular • How are we going to treat a 20-year-old who will have ~ 50+ years of IBD? Hanrahan, TP. Future Pharmacol. 2022, 2, 669–680.
  16. MICHIGAN IBD MICHIGAN IBD Sequencing: Biologic (anti-TNF) Experience Matters A

    Lot for Some Drugs 0 5 10 15 20 25 Adalimumab Vedolizumab Ozanimod Percent Clinical Remission in UC TNF Naive on Drug TNF Naïve on Placebo TNF-Experienced on Drug TNF-Experienced on Placebo Delta 15.5 Delta 5.4 Delta 10.3 Delta 2.3 Delta 16.5 Delta 6.5 Therapeutic Advances in Gastroenterology 2023 Brian Bressler https://doi.org/10.1177/ 17562848231159452 Losing 2/3 of Effectiveness If not used 1st line But lose only 1/3 (Uste) , 1/2 (Risa) or none of Effectiveness for Tofa & Upa ADA Vedo Oza 1st line or not at all Post-TNF, Consider Upa Tofa Uste Risa
  17. MICHIGAN IBD Timing of Biologics: Controlling inflammation first helps large

    biologic molecules • Best baseline single predictor of week 52 CS-free remission with Vedolizumab for UC • Best baseline single predictor of week 52 CS-free remission with Ustekinumab for CD FCP < 236 mg/g stool Aliment Pharmacol Ther. 2018 Mar; 47(6): 763–772. CRP < 14.6 mg/L JAMA Netw Open. 2019;2(5):e193721. What baseline measure best predicts biologic success?
  18. MICHIGAN IBD Small molecules are often better (for rapid induction)

    than large molecules Bowel blazing hot – Delay biologics Bowel smoldering – Ready for biologic start Small molecules Can be a bridge
  19. MICHIGAN IBD MICHIGAN IBD Timing in PROFILE : New Crohn’s

    Dx = Emergency • New Diagnosis of Crohn's • Randomized to usual care (5-ASA, Aza) vs IFX • Start Rx within 14 days • 64% fewer surgeries or steroids in the first year • Treat new CD as an emergency • Get patients on effective Rx (biologic or JAKi?) within 2 weeks. The clock is ticking. • Prevent complications of disease. • We need insurers on board • We need 'new diagnosis' clinics • Is Time (early & effective Rx) the wonder drug? Noor, et al, Lancet GH, 2024; 9: 415-427.
  20. MICHIGAN IBD MICHIGAN IBD Personalising IBD Therapy in Practice Today

    If the patient can't access or won't take the medicine, it will not work Favor Anti-IL23 or 12/23 after TNF-induced psoriasis, or with IBD & autoimmune skin disease Treat EARLY with advanced therapy, especially in Crohn's to prevent bowel damage Reduce inflammation to smoldering with small molecules before starting biologics? Avoid extended corticosteroids – visceral fat is an inflammation depot, it could make other therapies less effective? A precise personalized choice of therapies for every patient may be coming (someday) ?
  21. MICHIGAN IBD MICHIGAN IBD Can Multi-Omics Ever Work? It took

    34 years to reach ipilimumab approval in 2011 It looked unlikely in the 1990s, and grants were hard to get