The cost of treating inflammatory bowel disease: step-up vs step-down, therapeutic drug monitoring and personalised medicine

Abstract

Inflammatory bowel disease (IBD) is a group of lifelong immune-mediated diseases, including Crohn's disease and ulcerative colitis. IBD is traditionally treated with drugs, including 5-aminosalicylates, steroids and immunosuppressants. However, the treatment landscape is changing, owing to a number of factors of significance to the IBD clinical nurse specialist. The recent introduction of novel biologic and biosimilar medications has affected the efficacy and cost of treatment. The established step-up treatment paradigm, where patients are started on simpler, cheaper therapies, is shifting toward a step-down approach, where biologics are the first-line treatment. Meanwhile, nurse-led pro-active therapeutic drug monitoring, including patient-reported outcome measures (PROMs), is helping ensure the efficacy and safety of treatment and allows for adjustments. In the near future, personalised medicine may offer genetic testing to predict a patient's reaction to different drugs and identify the most appropriate therapies. At the author's hospital, some of these factors may have contributed to a 50% reduction in emergency surgical rates for ulcerative colitis. This clinical review examines these issues in light of real-world experience from the author's hospital.