In corporate industry, risk can be a creator of value and can play a unique role in driving business performance, and so strategies for corporate risk management must be developed to help guide the business as it decides which risks to take. Risk management, then, is the identification, assessment and prioritization of risks or uncertainties in business. Any strategies for corporate risk management must be backed up by a risk management analysis and a plan for controlling or mitigating those risks. Rules-based modeling can mitigate many medical risks. Available clinical data have translated into best-practice consensus guidelines in the management of IBD. Where possible, consensus needs to be appropriate for local resources and regulatory authorities. They should be developed by national organizations and societies by a group of cross-discipline healthcare providers. In acute severe ulcerative colitis, risk may be measured as death or colectomy. The Australian IBD Consensus Working Group developed consensus statements on the management of acute severe ulcerative colitis that can be easily found by online search terms “GESA acute severe ulcerative colitis.”5 The document shows the level of evidence and provides grades for each statement. Further, the consensus statement guides readers in the identification of the presenting condition, highlights relevant investigations required, and provides advice on areas such as the need for unprepared sigmoidoscopy and treatment pathways. Corticosteroids are the mainstays of induction therapy in IBD. Risks of complications accumulate with extended use, but underutilization of corticosteroids may be associated with failure to induce clinical remission and ongoing poor quality of life. Chronic use of corticosteroids is an immediate trigger for treatment escalation. This is most relevant in the older patients, a group where overutilization of systemic immunosuppression is discouraged. In older patients and those with significant comorbidities, a survey of gastroenterologists showed that vedolizumab was more frequently prescribed than immunomodulators and anti-tumor necrosis factor (TNF) biological agents in this patient population (TNF P < 0.0001).6 Another cohort study of 255 patients with IBD from the Sydney IBD Cohort showed that patient age was not a barrier to the introduction of immunomodulators, but the presence of comorbidities was.7 In that study, the benefit of commencing immunomodulators early was seen in both young- and elderly-onset Crohn's disease with a significant reduction in abdominal and perianal surgery (HR: 0.177, 95% CI: 0.089–0.351).8 Overseas travel, although reduced since the SARS-CoV2 (COVID-19) pandemic, is a frequently encountered topic of discussion during consultations. Patients with IBD treated with systemic immunosuppressive drugs are at risk of opportunistic infections when travelling overseas, but many of these risks can be mitigated through preventative and surveillance strategies.7 Vaccination and risk avoidance strategies are required in high-risk areas of the Asia-Pacific, and screening for latent tuberculosis can be recommended following return from high tuberculosis-prevalence regions. A survey of 305 gastroenterologists from 23 countries identified only half of all respondents discussed travel-related issues with patients, and there was great variability in the advice given.9 Another international survey of 2491 IBD subjects found that over a third of all patients did not seek medical advice prior to overseas travel indicating pre-emptive discussions on travel to be appropriate.10 A discussion of risk is complex and sometimes not possible due to the many competing topics that need to be covered. The above examples are merely some of the areas where risk mitigation is possible. This summary aims to remind readers of the need to consider risks encountered, but this includes the risk of undertreating patients and not just risks of treatments. Risks are also dynamic and change with patients' growing age, disease condition, changes in life circumstances, and the acquisition of other comorbidities. The dynamic nature means the need for constant evaluation of risks over other competing health conditions that the patient faces. Prof Rupert Leong served on the advisory boards of AbbVie, Aspen, BMS, Celgene, Chiesi, Ferring, Glutagen, Hospira, Janssen, MSD, Novartis, Pfizer, Takeda and has received research grants from NHMRC, Endochoice, Shire, Janssen, Takeda, Gastroenterological Society of Australia, Gutsy Group Funded through an unrestricted educational grant from Takeda Pharmaceuticals Pty Ltd.
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