Bridging the north-south divide

Sandra Ryan speaks to Irish Society of Gastroenterology President Dr Tony Tham in advance of the Society’s Winter Meeting 2019

Specialists will gather in Fitzpatrick’s Castle Hotel in Killiney, Co Dublin, on 21-22 November for the annual Irish Society of Gastroenterology (ISG) Winter Meeting, where topics for discussion include an update on managing autoimmune hepatitis; a clinical overview of guidelines for lower GI bleeds; and a talk on how personalised medicine may be the future of inflammatory bowel disease (IBD) management.

The ISG has always been unique, in that it is an organisation covering the island of Ireland, and this year’s President reflects that — the first in 19 years from Northern Ireland.

Dr Tony Tham has been Consultant Physician and Gastroenterologist in the Ulster Hospital, Dundonald, Belfast, since 1997 and is current President of the ISG.

He has been instrumental in developing gastroenterology services in the Ulster Hospital, especially in therapeutic endoscopy and endoscopic retrograde cholangiopancreatography (ERCP).

Speaking to the Medical Independent ahead of the Winter Meeting, Dr Tham explained that one of his goals while President is to foster greater engagement and communication between specialists on the island of Ireland. As part of this goal, this year’s meeting will, for the first time, host a special networking event on the first day — the first Irish leaders in gastroenterology forum.

“One of my aims, and the Society’s aims overall, is to foster engagement among specialists in both the north and south of Ireland,” said Dr Tham. “On 22 November, the forum will be an opportunity to meet and learn from our colleagues across Ireland. The idea is that networks can form and strategies can align for the greater good — to improve the lives of patients with GI and liver disease on the island of Ireland.”

He explained that the forum is essentially a pilot initiative and if successful, will form part of future ISG meetings.

Dr Tham describes his overall strategy as President as ‘the three Es’: Education, engagement, and Europe.

The latter refers to the goal of aligning further with specialists in Europe. To this end, the ISG has been instrumental in ensuring that Dublin is home to next year’s European Society of Gastrointestinal Endoscopy (ESGE) conference, taking place in the Convention Centre, Dublin, on April 23-25 2020.

“Ireland is known in Europe for punching above its weight when it comes to gastroenterology knowledge sharing and research,” said Dr Thom, “especially for the number of specialists we have for a country this size. Bringing the ESGE Days 2020 conference to Dublin is a big coup for us and the ISG is joining our British counterparts, the British Society of Gastroenterology, to host a special symposium during the event.”

Dr Tham is keen to ensure that gastroenterologists north and south can learn from each other. He said the trend in Ireland whereby many gastroenterology specialists are spending their time on general medicine, as opposed to more specialised aspects of gastroenterology, is also seen in Northern Ireland and parts of the UK.

These issues were discussed at the most recent Summer Meeting of the ISG.

“Challenges in the specialty in Ireland are similar on the NHS, generally,” said Dr Tham. “Our focus is to find a balance — so that specialists are not spending all their time on general internal medicine, but also not only focused on the more specialised patients.”

He said that in many UK hospitals, and in one of the five NHS trusts in Northern Ireland, gastroenterology on-call rotas are separate from general medicine rotas.

“It’s hard to know if this model – where GI on-call is separated from general medicine – is best, because I believe generally patients, at least in the UK, want more doctors specialising in general medicine available to them, rather than very specialised physicians. So we have to find a balance.”

Personalised medicine in IBD

At the Winter Meeting, Dr Tariq Ahmad from the University of Exeter Medical School, UK, will deliver a presentation titled ‘Personalised Medicine in IBD — Are We There Yet?’

Dr Ahmed recently led a ground-breaking and large-scale NHS research collaboration, which discovered a gene mutation that allows the identification of patients at risk of side-effects from thiopurines, allowing doctors to tailor alternative treatments to these individuals. The research was published in February 2019 in JAMA.

Drugs to suppress the immune system are the mainstay of IBD treatment, but more than half of patients with Crohn’s disease and about 20 per cent of patients with ulcerative colitis will require surgery at some point, Dr Ahmed’s study states.

About one-third of patients with IBD are treated with a thiopurine drug; however, approximately 7 per cent of patients develop bone marrow suppression, a side effect of treatment.

Previous studies have identified mutations in a gene known as TPMT, which predisposes patients to thiopurine-induced bone marrow suppression. Doctors either adjust the dose or avoid thiopurines altogether if routine tests show that patients are likely to carry faulty versions of the TPMT gene. However, only a quarter of patients who suffer from bone-marrow suppression have abnormalities in TPMT, suggesting that other genes may be involved.

In Dr Ahmed’s study, which was funded by the charities Crohn’s and Colitis UK, for Crohn’s, and the International Serious Adverse Event Consortium (ISAEC), DNA from approximately 500 patients with IBD who suffered thiopurine-induced bone marrow suppression and 680 controls (IBD patients who had received thiopurines and had no history of bone marrow suppression) were analysed to identify  genes possibly associated with this adverse drug reaction.

The researchers found an association between mutations in a gene called NUDT15 and bone marrow suppression. This gene mutation had previously only been thought important in patients of East Asian descent, the study states.

According to Dr Ahmad, who was chief investigator of the study, the discovery of this gene variation can help identify who is susceptible to thiopurine-induced bone marrow suppression. 

In the UK, the NHS has a 10-year plan to increase personalised medicine generally, and it is hoped that testing for this genetic abnormality prior to prescribing thiopurine drugs will reduce the risks to patients, and costs to the NHS, associated with this potentially serious drug side-effect.

“Working with patients and clinicians from across the UK, we have shown the power of the NHS to deliver clinically-meaningful genetic research outcomes.”

Visit www.isge.ie for more information about the Winter Meeting