Gastroenterology Associates of Big Bend, Tallahassee, FL, USAUnited States
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Yogi Berra philosophized, “You can observe a lot by just watching.” Physicians managing inflammatory bowel disease (IBD) patients are constantly exposed to the recent literature, the visiting pharmaceutical representatives, and to the valuable presentations by the academic experts at the annual meetings. In my opinion, these presentations too often are advanced in a vacuum of unconvincing compartmentalization rather than as a well-choreographed management strategy that considers both the impact of any IBD drug and the nearly certain likelihood of a patient’s failed response or eventual relapse.
Open Journal Opinion What IBD Physicians Can Learn from Major League Baseball Managers * Nicholas V. Costrini, MD, PhD, MBA* Gastroenterology Associates of Big Bend,Tallahassee, FL, USA * *Corresponding author Nicholas V. Costrini, MD, PhD, MBA Gastroenterology Associates of Big Bend,Tallahassee, FL, USA; E-mail: drcostn@gmail.com Article information st th th Received: November 1 , 2019; Accepted: November 4 , 2019; Published: November 6 , 2019 Cite this article Costrini NV. What IBD physicians can learn from major league baseball managers. Gastro Open J. 2019; 4(1): 7-8. doi: 10.17140/GOJ-4-130 ogi Berra philosophized, “You can observe a lot by just watching.” 2. Starting Pitchers seldom hold the mound past six innings. Physicians managing inflammatory bowel disease (IBD) pa- Y tients are constantly exposed to the recent literature, the visiting 3. Starting Pitchers’ inning-by-inning earned run averages pharmaceutical representatives, and to the valuable presentations (ERA) rise after the fourth inning.
by the academic experts at the annual meetings. In my opinion, these presentations too often are advanced in a vacuum of uncon- 4. Managers monitor the Starting Pitcher effectiveness (ERA vincing compartmentalization rather than as a well-choreographed per inning); in IBD, clinical status and fecal calprotectin require management strategy that considers both the impact of any IBD intense monitoring3 which has been lack-luster for decades. drug and the nearly certain likelihood of a patient’s failed response or eventual relapse. Stated another way, what is most often missed, only mentioned as an aside, and almost never clearly defined is 5. In MLB managers know the bullpen expertise and prior an agent’s place within the context of management of the entire work; in IBD, physicians must know the classes of drugs in the course of the disease. Twenty years into the new century with the IBD armamentarium.
current and evolving list of IBD drugs, it would be valuable to a. Mesalamine/Steroids/Immunosuppressants/Biologics/ much more often and with authority present specific management Small molecules 1,2 algorithms that offer the highest likelihood of remission.1,2 Having b. Make decision based upon disease/activity/urgency of a progressively enlarging menu of partially effective drugs is no need/prior drugs exposure longer satisfactory. I give you Major League Baseball (MLB). 6. Starting Pitchers wins 90% of Cy Young (best pitcher of the We appropriately view the physician’s role as that of the year) Awards even though they seldom pitch a complete game. manager of the IBD case and particularly as manager of the med- Similarly, the starting biologic should be expected to bring ications employed. As an instruction, I offer what we can learn 4-6 about complete remission in only a quarter of the cases. from MLB managers as we observe the well-defined strategy in 3 Discuss a total medication strategy with patients. Advise that calling Starting and Relief Pitchers to the mound. non-responsiveness and relapse are likely and the management strategy provides for these eventualities.
1. Great Pitching (i.e. The first IBD drug employed) beats Great Hitting (i.e. moderate to severe IBD). Both starting and 7. The Relievers have lower ERAs than the Starting Pitchers Relief Pitching are necessary. In IBD, we have good but not and promote winning seasons. Consider Anti-TNFs, T-Cell great drugs at the present time. Follow-up (i.e. relief) medica- Migration Inhibitors, IL 12/23 Inhibitors, JAK inhibitors as tions are an essential part of the strategy for IBD. Any discus- essential management choices which should be outlined in the sion of a specific drug must include a recommendation for use course management from the outset. To be clear, do not cling in an over-all strategy leading to remission and change in the to the idea that the first biologic will secure long-term remis- natural history of IBD.
sion. Rather, plan with the patient that a change will be re- cc Copyright 2019 by Costrini NV. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which Gastro Open J. 2019; 4(1): 7-8. doi: 10.17140/GOJ-4-130 quired and seek the ideal time and agent for the change.