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Treat-to-target (T2T) strategies aim to achieve remission by adjusting therapy to achieve predetermined targets such as clinical symptoms, mucosal healing, biomarkers, and patient-reported outcomes.(Ungaro 2019)
The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) committee recommended objective disease activity measurements for T2T approaches to UC in 2015 (Peyrin-Biroulet 2015)
  • Resolution of rectal bleeding/normalization of bowel habits
  • A Mayo endoscopic subscore of ≤1 (0 is ideal)
If targets not met within 3 months during active disease, adjust therapy
A recent update expanded on the use of endoscopic and histological targets over symptomatic management and proposed a T2T algorithm (Ungaro 2019)
Dr. Nandi reviews T2T strategies
These strategies are common in rheumatoid arthritis and have also recently been explored in Crohn’s disease and UC.
Patients with UC should understand the specific goals of T2T and make sure they agree with the treatment targets.
  • Motivated and informed patients will be more adherent and compliant with protocols.
  • Patient adherence to a T2T approach requires their acceptance of dose escalation, even when they are not experiencing any symptoms, if your goal is deeper level healing or remission.
Dr. Nandi discusses how he describes T2T to his patients
Personalized regimens should consider:
UC has a significant psychosocial impact on patients.
The patient-physician relationship is integral to the continuum of care in UC management:
  • Perceived stigmatization can influence patients’ engagement with healthcare providers.
  • Patients’ readiness to discuss their UC is influenced by the individual’s understanding and acceptance of their UC.
Dr. Nandi describes how he engages UC patients

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Do you know how UC affects your patients’ health-related quality of life (QoL) and influences their treatment goals? Qualitative data from gastroenterologists and UC patients indicate that patients aren’t asked about their QoL, and treatment goals aren’t aligned between clinicians and UC patients.(Rubin 2017)
Differences in patient and physician goals of treatment (Adapted from Chew 2018)
Patient factors that may compromise UC care (Adapted from Drescher 2019)
Barriers and solutions to communicating about inflammatory bowel disease (Adapted from Chew 2018)
  • Challenges Mechanism of Impact Ways to Overcome
    Acceptance of chronic disease Unpredictable remitting-relapsing course Educating patients on treatment options to induce remission and importance of adherence in optimal outcome
    Impact of UC on quality of life Physiological distress Promptly identifying patients who have psychological distress and instituting measures such as taking more time to explain and explore and referral to psychiatrist as needed
    Non-adherence Poor outcomes in UC Shared decision-making; treat-to-target; motivational interviewing
Stepwise approach to improving patient-physician communication (Adapted from Chew 2018)
  • Time Course of UC Patient Physician’s Role
    Pre-diagnosis Endurance of UC symptoms without definite diagnosis resulting in frustration
    At diagnosis 5 stages of grief Recognize the patient's stage of grief
    Questions regarding UC:
    -Etiology
    -Is it infectious?
    -Can I be cured?
    -Does this disease affect only the GI tract?     		Explain the nature of its relapsing-remitting course and although there is no cure, there are vast treatment options to facilitate remission
    Feelings of isolation, of carrying disease labels, flaw of how UC will affect their life: career prospects, relationships, children, and activities of daily living Address concerns. Invite partners to be part of the UC journey. Ascertain the amount of social support. Remedial actions for poor social support
    Reports of subjective symptoms of UC Assess pretreatment objective and subjective scores
    Patients' role as health partners and being jointly involved in the decision-making process in order to reach evidence-based patient-centered decision Explain the remission induction and remission maintenance options, and come to a joint decision via shared decision-making on treatment strategy
    Prioritization of symptomatic regression and a misconception of histological remission Explain the objective and subjective parameters monitored and their importance, and come to an agreement with patients on the treatment targets: stress that failure to achieve would hence result in escalation of therapy
    Reports of subjective symptoms of UC. Revisit the subjective and objective parameters monitored to assess if treatment is effective
This brief whiteboard animation was developed to help patients with UC understand what factors influence treatment decisions and how to gauge whether their therapy is optimized. Share this resource to partner with your patients!
This whiteboard can also be viewed on the Girls With Guts website along with encouraging and supportive patient videos, education, and resources.

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