Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease

Abstract

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.

Keywords: Crohn’s disease; clinical complexity; internal medicine; precision medicine; ulcerative colitis.

Figure 1

Schematic representation of disease-, drug-, and patient-related factors to be considered in the overall management of inflammatory bowel disease (IBD). The factors depicted in the Figure encompasses the four main domains of the 4P medicine, including prediction, prevention, participation, and personalization. Current guidelines do not comprehensively cover these aspects, that all pertain to an internal medicine setting. Indeed, many other variables not depicted in the Figure should also be considered and discussed with patients.

Figure 2

Schematic representation of the management of patients with inflammatory bowel disease treated with immunosuppressants or biologics and developing a viral colitis sustained by human cytomegalovirus (HCMV) and/or Epstein–Barr virus (EBV). Depending on colitis refractoriness and the viral load, different scenarios are depicted. The assessment of the viral load is crucial, as HCMV and EBV may be normally found in very low concentrations in the gut mucosa and are considered innocent bystanders in this case.