Why You Should Ask for a Treat-to-Target Approach for Your UC
This relatively new, proactive treatment approach for ulcerative colitis may lead to the lasting relief you want.
Maybe you’re in the bathroom multiple times a day with diarrhea (or feeling like you still have to go) or you’re finding yourself exhausted and feverish. Whatever your symptoms, if you have ulcerative colitis (UC), you might think of your gastroenterologist as your very best friend when they flare up. But what would it be like if you weren’t only seeing your doctor in a crisis?
Until fairly recently, treating UC has been about controlling symptoms like diarrhea, abdominal pain, urgency, bloody stool, and fatigue. But these days, many gastroenterologists are taking a different treatment approach called treat-to-target, which means they focus on specific treatment goals related to both alleviating symptoms and healing your colon.
A Shift in Strategy
Treat-to-target is a term that has been borrowed from other areas of medicine that have used this approach for decades, says Gil Y. Melmed, M.D., director of inflammatory bowel disease clinical research at Cedars-Sinai Medical Center in Los Angeles. In a nutshell, “it’s being proactive instead of reactive. For a long time, this just wasn’t how we treated ulcerative colitis,” Dr. Melmed says.
It used to be that patients were started on medication and then their doctors waited for them to flare, treating them on an as-needed basis, says Aline Charabaty, M.D., clinical director of the GI division and director of the IBD center at Johns Hopkins-Sibley Memorial Hospital in Washington, D.C. Then they were treated with steroids and if they had symptoms again, their treatment plan might be adjusted.
But doctors now know it’s not enough to just look at symptoms, because even when you’re feeling good your colon may still be irritated and inflamed. The treat-to-target approach instead focuses on getting you into remission and preventing future flares. “The idea is that we’re proactively measuring the state of your colitis, independent of your symptoms,” Dr. Melmed says. You’re treated and consistently monitored to see if you’ve achieved your target, or goal, of treatment. If you haven’t, your treatment strategy is readjusted until you do.
Dr. Melmed gives the example of people with diabetes or high blood pressure, who always have a specific blood-sugar or blood-pressure goal. To meet that, their doctors keep adjusting their medications and monitoring their numbers until they get there. A treat-to-target approach in UC works in the same way.
The Ideal Target
So, what’s the goal? In UC, the ideal target is a combination of having no symptoms (symptomatic or clinical remission) and having visual evidence that the bowel is healed (via a colonoscopy, preferably), according to Dr. Melmed. But what does that mean exactly and why is it important?
It’s obvious why having no symptoms is one half of the target—everyone wants to feel better—but being symptom-free is actually not quite as simple as it sounds. Yes, making sure you don’t have blood in your stool, that you’re not running to the bathroom constantly, and that your diarrhea is a distant memory is a given. But it’s just as important to make sure you’re not having some of the other UC-associated issues, what are known as the “extraintestinal symptoms,” like joint pain and inflammation, eye inflammation, and skin lesions, says Dr. Charabaty. Any of these symptoms is a sign that the disease is still active.
Not only that, but Dr. Melmed says it’s important to understand that you can’t tell how your UC is doing just by your symptoms (or lack thereof). You may feel better or even back to normal once you’ve started a new medication, yet your colon could still be inflamed. “We know now that if that’s the case, then there’s a significant risk for flare-up of the disease and for complications down the road,” he says. Dr. Charabaty adds that colon inflammation also increases your risk of hospitalization and needing surgery. This is why endoscopic evidence of bowel healing is the second piece of the ideal UC target.
Another reason bowel healing is important is because when you have UC for more than seven years and it involves a large part of your colon, Dr. Charabaty says you’re at increased risk for colon cancer. She tells her patients it’s just like how getting sunburned repeatedly increases your risk for skin cancer—when your colon is chronically inflamed for a long period of time, your risk for colon cancer goes up too.
“Targets can be different depending on period of life, overall health, and patient goals,” Dr. Charabaty says. For example, her target for a young patient with their whole life ahead of them is different than her target for an 80-year-old patient who might be at a higher risk of complications if they take a more aggressive medication. “My target for them is to be comfortable and not have to run to the bathroom and fall on the way,” she explains. It’s also important to consider what your own goals are and what you want to achieve in your treatment, says Dr. Charabaty.
What to Expect
You might be wondering what the difference is between a traditional treatment approach to UC (reactive) and the treat-to-target approach (proactive) really looks like. In practice, probably the two biggest differences are that with the treat-to-target approach, you’re getting regular colonoscopies and/or other tests to check on your bowel healing and you’re having more regular follow-ups with your gastroenterologist.
Dr. Charabaty gives this example to illustrate the difference between the two approaches: A patient comes in for a follow-up after being given medication because he was having 15 bowel movements a day. Now he’s down to four a day and there’s still a little bit of blood in his stool here and there. His blood tests and/or colonoscopy still show some inflammation. “In the old days, we used to be like, ‘That’s good enough,’ but now we know we need to push further to achieve as much remission as we can,” she says.
Instead, Dr. Charabaty wants this patient to go back to having just one bowel movement per day, having no blood in his stool, and showing evidence that his colon has healed. She achieves this by changing the treatment, increasing the dose of the current treatment, or adding another treatment. Then she sees the patient regularly to see if the treatment is working. “If it’s working, perfect. We’ll reassess periodically. If it’s not working, what can I do to adjust it? Can I change the dose? Do I need a different medication? What do I need to do to get to my target?”
Effective UC therapy can be different for each individual but may include drugs like biologics or immunosuppressants (or a combo). “We want to prevent disability and missing time from work and being in the ER or being in the hospital or needing surgery for UC,” says Dr. Charabaty. She adds that she knows many people with UC are worried about taking these new medications and about their side effects. “It’s important to remember that not treating the disease properly puts the patient at higher risk of complications than those medications,” she says.
Another one of the goals of effective therapy is to keep UC in remission without having to use corticosteroids, according to Dr. Charabaty. “There are still patients being treated with just prednisone. When they flare, they take prednisone and when they’re better, it’s cut down. That is not the right treatment,” she says. Not only do steroids have serious side effects, but they don’t heal the bowel or prevent another flare. “It’s a quick fix that we use temporarily to control symptoms until we have an effective treatment in place.”
Getting Your Doc on Board
If you’re only seeing your gastroenterologist when you’re in crisis mode, you haven’t been given one of the new drug therapies like Xeljanz (tofacitinib), Remicade (infliximab), Humira (adalimumab), or Simponi (golimumab) to treat your UC, and/or you don’t know when or how you’re going to tell if the therapy is working, it might be time for a discussion. Dr. Melmed says that it’s important for patients to understand the concept of a treat-to-target approach and bring it up with their doctors if they’re not getting this approach already. “Certainly, if you’ve gone more than a year without having an evaluation, that really begs a conversation with your physician,” he says.
Dr. Melmed says when he starts a patient on medication, he also sets them up for the next steps. He usually does a colonoscopy six to nine months later because these medications should be effective enough to heal the bowel by then. If the medication hasn’t done the job, he makes a change. “Symptoms alone are not good enough to understand whether a drug is working. Colonoscopy is the best way to evaluate the state of inflammation, but there may be other less invasive tests like blood tests, stool tests, and imaging tests as well,” he says.
If you’re going to advocate for a treat-to-target approach with your doctor, Dr. Melmed and Dr. Charabaty suggest asking questions like these:
Why are we doing a colonoscopy? What are we looking for?
What are we going to do with the results?
How will you know that this new drug is going to work?
Are my symptoms getting better?
Should we be doing more invasive tests to clarify whether my bowel is actually healed? And if it’s not, then what are we going to do and when?
Is this the right drug for the degree of severity of my disease?
When should I expect to feel better?
When are we going to assess if my colon is healing? Will we use bloodwork, stool tests, or colonoscopy?
How often are we going to monitor my inflammation markers?
What is plan B if this treatment doesn’t work?
Keep in mind too that your doctor might just be thrilled that you’ve spoken up. Dr. Charabaty says some physicians feel uncomfortable suggesting close monitoring, but when you, the patient, are proactive, knowledgeable, and motivated to get well, “it changes the tone of the conversation.” And the benefits of a treat-to-target approach—preventing flare-ups and complications and lessening your risk of hospitalization, surgery, and colon cancer—are well worth a potentially awkward discussion.
Ulcerative Colitis Symptoms: Mayo Clinic. (2020.) “Ulcerative colitis: Symptoms & causes.” mayoclinic.org/diseases-conditions/ulcerative-colitis/symptoms-causes/syc-20353326
Ulcerative Colitis Treatments: Mayo Clinic. (2020.) “Ulcerative colitis: Diagnosis & treatment.” mayoclinic.org/diseases-conditions/ulcerative-colitis/diagnosis-treatment/drc-20353331