The Risk of Cardiovascular Complications in Patients with Inflammatory Bowel Disease
Inflammatory bowel disease (IBD), encompassing Crohn’s disease and ulcerative colitis (UC), is a chronic, relapsing-remitting inflammatory condition of the gastrointestinal tract. Beyond intestinal involvement, IBD commonly affects diverse organ systems in the body, making it a ‘systemic disease with intestinal predominance’. While extraintestinal manifestations are primarily due to immune-mediated involvement of organ systems, IBD also exerts systemic effects on the cardiovascular system. Emerging data suggests an association between IBD and myocardial infarction (MI), ischemic heart disease, cerebrovascular accidents, and other major adverse cardiovascular events (MACE). As a result, the pathophysiological basis of cardiovascular complications in IBD has been a subject of growing investigation.
Copyright (c) 2026 Canadian IBD Today https://creativecommons.org/licenses/by-nc-nd/4.0
2025: The Inflammatory Bowel Disease (IBD) Year in Review
Effective and well-tolerated dietary therapies for Crohn’s disease have long been sought by both patients and providers. In pediatric inflammatory bowel disease (IBD), exclusive enteral nutrition (EEN) has gained traction and is recommended by treatment guidelines. However, it has not been broadly implemented in adults due to poor tolerability, social constraints, and challenges with long-term adherence. Consequently, there is a growing interest in dietary interventions that offer efficacy while imposing a lower burden on patients. TASTI-MM is the first randomized controlled trial to provide evidence supporting an exclusive whole-food dietary strategy to treat active Crohn’s disease. Previous evidence for whole‑food approaches was limited to observational cohorts. This trial sought to determine whether a whole food diet could enhance compliance in comparison with EEN, improve disease activity, and modify the microbiome with the goal of sustained disease control.
Optimizing the Risk-benefit Conversation with Inflammatory Bowel Disease Patients
Key Takeaways: Contextualize Treatment Options Against the Risk of No Treatment: A primary driver of therapeutic hesitancy is a disproportionate fear of medication side effects. Clinicians must counter this by clearly articulating the severe and often certain morbidity associated with untreated intestinal inflammation. Leverage the Safety Profile of Selective Pathways: The expansion of the therapeutic armamentarium allows for more personalized efficacy and safety considerations. Factor this in when helping patients choose appropriate treatment options (ie. Treatments that will treat extra-intestinal manifestations; treatments with impeccable safety profiles for those patients exceptionally anxious over side effects). Utilize Structured Communication Models: Effective communication is the cornerstone of the therapeutic alliance, yet many patients report that treatment discussions are often brief and lack depth. Adopting a structured framework can ensure a collaborative rather than directive process. Address the Disconnect in Treatment Goals: There is a significant disconnect between what clinicians measure and what patients experience. While doctors focus on objective markers like fecal calprotectin and endoscopic findings, patients are often most burdened by bowel urgency. Centring the risk-benefit conversation on the restoration of social and professional functioning—rather than just laboratory targets—can meaningfully improve patient satisfaction and long-term treatment adherence.
Recent Clinical Trials in Acute Severe Ulcerative Colitis: Can We Improve the Chances of Success of Corticosteroids and Rescue Therapies?
Key Takeaways 1. Don’t withhold intravenous (IV) steroids waiting for the stool infectious workup to come back. Many patients with infectious etiologies for exacerbation will require antimicrobials plus steroids to manage severe relapses. 2. When considering infliximab rescue therapy, a 10 mg/kg dose likely leads to higher response rates among patients with hypoalbuminemia (<25 g/L) and elevated CRP (≥50 mg/L) than a 5 mg/kg dose 3. JAK inhibitors can be considered as an adjunct to IV steroids, or as rescue therapy in steroid-refractory patients with a history of anti-TNF failure.
Beyond the Gut: Metabolic Dysfunction-associated Steatotic Liver Disease in Inflammatory Bowel Disease
Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a frequent and clinically meaningful comorbidity in inflammatory bowel disease (IBD). Once considered incidental, MASLD is increasingly recognized as a marker of systemic metabolic and inflammatory burden with important hepatic and extrahepatic consequences. Recent studies indicate that MASLD affects approximately 24–32% of patients with IBD, with similar prevalence in Crohn’s disease and ulcerative colitis after adjustment for metabolic risk factors. Importantly, liver fibrosis, the key prognostic hallmark in chronic liver disease, is detected in a substantial subset of patients and appears to progress over time. The pathogenesis of MASLD in IBD reflects the convergence of classical metabolic dysfunction with IBD-specific factors, including chronic systemic inflammation, gut–liver axis alterations, and changes in body composition. Although IBD is not yet systematically included in MASLD screening recommendations, emerging epidemiological and longitudinal evidence supports adapting established metabolic screening pathways to the IBD population using a risk-stratified case- finding approach. Pragmatic two-step algorithms, employing simple serum-based scores followed by transient elastography in selected patients, offer scalable and implementation-ready strategies. Management of MASLD in patients with IBD should align with general population guidelines while accounting for disease‑specific considerations. Lifestyle modification remains foundational, complemented by pharmacologic therapies in patients with fibrosis or high cardiometabolic risk. Integrating liver risk assessment into routine IBD care represents a critical step toward improving long-term hepatic and extrahepatic outcomes in this growing population.
Pregnancy in Inflammatory Bowel Disease (IBD)
Key Takeaways • Preconception assessment and counselling is recommended for women with IBD who are contemplating pregnancy, ideally occurring at least 3 to 6 months prior to attempts at conception • Most IBD therapies are recommended to be continued throughout pregnancy and lactation to minimize the potential detrimental impact of active disease on infant and maternal outcomes • Consideration of aspirin commencement for preterm preeclampsia prevention is recommended, prior to 16 weeks gestation, in women with IBD, especially if additional risks for preeclampsia development • Infants exposed to biologics in utero can receive inactive vaccines and Rotavirus live vaccine per schedule.
Copyright (c) 2025 Canadian IBD Today https://creativecommons.org/licenses/by-nc-nd/4.0
Is IL-23 the Winner? Lessons from Inflammatory Bowel Disease (IBD) and Psoriasis (PsO)
Key Takeaways • Interleukin-23 (IL-23), and the IL-23/Th-17 interaction, plays a pivotal role in the pathogenesis of immune‑mediated diseases, such as psoriasis (PsO) and inflammatory bowel disease (IBD). This has led to the development and commercialization of several anti-IL-23 therapies, all demonstrating high efficacy and safety in the management of these conditions. • Anti-IL-23 therapies, have been shown to be amongst the most highly effective treatments in PsO, achieving meaningful and durable treatment response (PASI-90) in over 80 per cent of participants in registrational clinical trials, while in IBD the meaningful one-year efficacy, based on the varied definitions of the studies’ primary endpoints, is achieved (at most) in just over 50 per cent of participants, though rates of achieving remission in Crohn’s disease are much lower. • Several ongoing studies examining the role of IL-23 inhibition in specific IBD populations (ex. perianal Crohn’s disease), and studies examining the combination of IL-23 inhibitors with other targeted therapies, capitalizes on the excellent safety and efficacy profile of anti-IL-23, reflecting the long-term importance of these therapies in the IBD treatment landscape.
Artificial Intelligence in Inflammatory Bowel Disease (IBD) Diagnostics: Applications and Future Directions
Key Takeaways • AI can improve the accuracy, objectivity, and reproducibility of IBD disease assessments across multiple disease assessment indices. • Multiple AI models have shown expert-level performance in the assessment of endoscopic and histologic activity in IBD. • The deployment of AI models can help uniformize the quality of disease assessment across academic and community centres alike. • The next steps will involve multimodal AI models. The development of these models, and the fine-tuning of unimodal systems, will require large, diverse datasets and careful governance.
Inflammatory Joint Pain in Inflammatory Bowel Disease (IBD) Patients Treated with Anti‑Tumour Necrosis Factor (TNF) Therapy: Differentiating IBD Arthritis, Paradoxical Arthritis, Anti‑TNF‑induced Lupus, and Serum-Sickness-Like Reactions
Key Takeaways • We propose a mechanism based approach assessing bowel activity, timing of drug exposure and auto-antibody profile to manage arthritis in IBD patients treated with anti-TNF therapy. • Paradoxical arthritis, anti-TNF- induced lupus, and serum-sickness-like reaction can occur with anti-TNF therapy; all require a change in targeted therapy. • Managing arthritis in IBD requires multidisciplinary work between gastroenterologist and rheumatologist to optimize treatment of both manifestations.
Deprescribing Advanced Therapies in Inflammatory Bowel Diseas
Key Takeaways: • Deprescribing advanced therapies is a viable option for carefully-selected patients living with IBD. • We propose a systematic approach for deprescribing advanced therapies in IBD, which comprises strategic patient selection, comprehensive risk assessment, shared decision-making, rigorous monitoring, and a pre-defined rescue strategy. • Further research is needed to improve patient selection tools, optimize monitoring techniques, and clarify deprescribing strategies for newer agents.
Travelling with Inflammatory Bowel Disease: Clinical Considerations
Key Takeaways: • Pre-travel consultation is essential for safe and enjoyable travel. IBD patients and physicians should discuss necessary vaccinations and action plans as soon as possible. • Preparing for travel by packing a medical kit, necessary medications and obtaining adequate travel insurance can reduce stress and mitigate problems. • Pre-travel vaccination is an important part of the preparations for many IBD patients. Live vaccines are contraindicated in patients taking immunosuppressant medications. Expert advice from a travel medicine specialist can identify individual patient vaccinations needs. • There are several resources available to physicians and patients alike, to empower our patients and remove many of the barriers they face when travelling.
Cytomegalovirus Colitis in Inflammatory Bowel Disease The Eternal Debate: Foe or Innocent Bystander?
Key Takeaways: • The prevalence of CMV infection among patients with IBD ranges from 2 to 29%, with a higher prevalence in those with UC compared to CD. • Immunohistochemistry and tissue PCR, or both, are the recommended tests for diagnosing active CMV colitis. • CMV may be an active pathogenic participant in cases with a high density of CMV and severe disease activity. Thus, we recommend testing for CMV colitis in patients with a severe inflammatory burden who are not responding to conventional IBD therapy. • Patients with low CMV viral burden can likely be treated with immunosuppression alone, while patients with high viral density or medically refractory disease should be treated with antiviral therapy.
Isolated Perianal Fistulas: When and How Should I Investigate for Inflammatory Bowel Disease?
Key Takeaways: • Approximately, 5–10% of all perianal fistulizing Crohn’s disease (PFCD) patients will have isolated PFCD. High or complex tracts, multiple internal openings, chronicity, and refractoriness to treatment—along with patient factors—should raise suspicion for PFCD (isolated or not). • A negative initial luminal evaluation does not exclude CD — surveillance is key. Up to 25% of patients presenting initially with isolated complex fistulas develop luminal CD over time (median 2.5 years). Periodic reassessment with imaging, endoscopy, and symptom monitoring is critical to avoid missed or delayed diagnosis. • Diagnosis and management of isolated PFCD requires a multidisciplinary, patient‑centered approach. TOpClass criteria offer practical diagnostic guidance using clinical, radiologic, and histologic features. For patients with significant symptoms and complex isolated PFCD, anti-TNF therapy may be considered, though evidence is limited and optimal duration remains unclear.
Prevention of Venous Thromboembolism in Patients with Inflammatory Bowel Disease
Key Takeaways: • When reviewing inflammatory bowel disease (IBD) patients in the clinical setting, remember to review their medical history and screen for venous thromboembolism (VTE) risk factors. This will help to risk stratify them for future decision-making. • IBD patients admitted to hospital are at the highest risk of VTE. All IBD patients, regardless of reason for admission and disease activity, should receive VTE prophylaxis. • In the post-operative and post-discharge setting, all IBD patients should be classified as low, intermediate, or high risk of VTE. After carefully weighing the risks and benefits, high risk patients should be considered for extended VTE prophylaxis beyond hospital discharge.
The 5 Most Clinically Impactful Papers Published in 2024 and Beyond
This past year saw the publication of a number of highly influential papers that have had immediate impacts on how we care for patients with Inflammatory bowel disease (IBD). In this review, I have selected five articles detailing studies published since the beginning of 2024 that have already directly impacted how I manage the care of people living with IBD. These articles are essential reading for all Canadian physicians treating IBD.
Inflammatory Bowel Disease in the Elderly
The incidence of inflammatory bowel disease (IBD) among the elderly in Canada has increased from 1 out of 160 seniors in 2018, to 1 out of 88 seniors in 2023, representing 1.14% of the senior population. It is thought that more than one-third of all IBD patients will be over 60 years of age in the next decade. The prevalence is expected to increase due to a combination of new diagnoses as well as the aging of younger people already living with IBD. Elderly persons with IBD face unique challenges that younger people with IBD often do not, such as co-existing comorbidities, frailty, polypharmacy, and an increased risk of infections and cancer. While the therapeutic management of elderly persons with IBD is similar to that of younger people with IBD, it requires careful consideration of many different factors, and special attention is needed when weighing the risks and benefits of medical therapy.
Using Immunosuppressive Therapies to Treat Inflammatory Bowel Diseases (IBD) in the Post‑Cancer Setting
Inflammatory bowel diseases (IBD), including Crohn’s disease (CD), and ulcerative colitis (UC), are chronic immune-mediated inflammatory disorders (IMID) affecting both intestinal and extraintestinal organs. Chronic intestinal inflammation causes multifocal DNA damage, increasing the risks of intestinal cancers. While the widespread use of effective biologic and small molecule therapies and intensified immune modulating (IM) regimens in recent years may have contributed toward declining colorectal cancer risks, these treatments could have introduced unexpected cancer risks in organs not directly affected by IBD due to reduced immune surveillance. Among individuals with IBD, the use of thiopurines has been frequently associated with risks of lymphoma, non‑melanoma skin cancer (NMSC), and cervical cancer. Several large studies have also reported increased risks of lymphoma, and melanoma associated with anti-tumour necrosis factor alpha (anti‑TNF) therapies, although other studies have not shown these associations. A randomized controlled trial (RCT) in elderly individuals with rheumatoid arthritis (RA) and cardiovascular risk factors reported a slightly increased all‑cause cancer risk with the non-selective Janus kinase inhibitor (JAKi), tofacitinib. Other immunosuppressive (IS) therapies, including methotrexate, anti-interleukin (IL)‑12/23 or anti‑IL-23 therapies, anti-α4β7 integrin therapy, JAK-1-selective inhibitors (upadacitinib), and sphingosine-1-phosphate receptor agonists, have not been associated with increased cancer risks to date. However, some of these newer therapies have only been available for a few years. Given the low absolute risk of treatment‑related cancers, controlling underlying IBD with IS therapies is typically prioritized to improve quality of life and reduce IBD-related complications. However, the decision to start or continue IS therapy in individuals with current or prior malignancy is more complex, as immune surveillance may be more crucial for these patients. Clinical trials generally exclude patients with a cancer history, which limits the available evidence on cancer recurrence risks associated with specific therapies. Additionally, some cytotoxic chemotherapy regimens can control IBD for prolonged periods, suggesting that additional immunomodulation may be unnecessary, and potentially harmful, during cancer treatment. Conversely, hormonal, radiation, and immune checkpoint inhibitor therapies have been associated with increased risks of IBD flares. Therefore, a careful and collaborative approach with oncologists is essential for the optimal management of IBD patients diagnosed with cancer. Recently, the European Crohn’s and Colitis Organization (ECCO) and the American Gastroenterological Association (AGA) released practice recommendations regarding the use of IS therapies in individuals with IBD in the post‑cancer setting. This review summarizes the evidence regarding cancer risks associated with specific IBD therapies in this context and presents a management approach based on both scientific and practical considerations.
Is There Still a Role for Proactive Therapeutic Drug Monitoring (TDM) in Inflammatory Bowel Disease (IBD): A Review of the Literature
The management of biologic medications in inflammatory bowel disease (IBD) is complex due to the inter- and intra-individual variability in pharmacokinetics and pharmacodynamics. There exist important differences in drug uptake and metabolism depending on a variety of factors including dosing intervals, route of administration, gender, body weight, albumin levels, inflammation, immunogenicity, genetic variation and other concurrent therapies. Males and individuals with higher body weight exhibit increased drug clearance, and certain biologics are more immunogenic than others. Moreover, the presence of a high inflammatory state, as demonstrated by elevated CRP levels and low albumin levels, also increase drug clearance and are associated with worse clinical outcomes. Therapeutic drug monitoring (TDM) can be useful in titrating certain biologic medications in IBD patients. By measuring drug levels and screening for antibody formation, TDM allows physicians to evaluate and optimize response to medications. Using these values, physicians can determine whether patients are sub-optimally dosed and can benefit from a reinduction or dose escalation, or whether these patients have begun developing immune responses to these medications.
Obesity in Inflammatory Bowel Disease (IBD): Recognizing a Critical Modifier In Modern Disease Management
The notion of obesity as a disease remains controversial. A recent consensus from the Lancet Diabetes & Endocrinology Commission reframes obesity by distinguishing between “preclinical obesity,” defined as a state of excess adiposity with preserved organ function, and “clinical obesity,” defined as a chronic, systemic illness caused by excess adiposity and characterized by measurable dysfunction in organ systems or limitations in daily living activities. This distinction provides a medically meaningful basis to identify when obesity constitutes a disease in its own right. Historically, inflammatory bowel disease (IBD) was associated with undernutrition and weight loss, a reflection of both disease activity and malabsorption. However, with shifting demographics, improved therapeutic options, and global lifestyle changes, obesity has emerged as an increasingly relevant coexisting condition in patients with IBD. While the current prevalence of overweight and obesity among Canadians with IBD remains unknown, population-level data from Statistics Canada show that 35.8% of adults in urban centers are classified as overweight, and 29.0% as obese. This epidemiologic shift has important clinical ramifications. Obesity contributes to systemic inflammation and is associated with increased healthcare utilization and reduced quality of life (QoL), which are burdens already faced by patients with IBD. The intersection of these two chronic conditions introduces complex challenges for disease management, health outcomes, and healthcare systems. This review explores the clinical impact of obesity in patients with IBD, including its influence on disease phenotype, treatment response, surgical outcomes, and QoL.
A Review of Pediatric to Adult Transition of Care in Inflammatory Bowel Disease
Canada is reported to have one of the highest rates of both incidence and prevalence of inflammatory bowel disease (IBD). Benchimol et al. conducted a population-based cohort study from 1999-2008 using health administrative data from Ontario, Canada, and reported that the prevalence of IBD in Canada in 2008 was 534.3 per 100,000 people (68,017 affected individuals among 12,738,350 Ontario residents). Between 1999 and 2008, the incidence of IBD increased annually in children under the age of 10 (9.7% per year, p<0.0001) and in those aged 10-19 (3.8% per year, p<0.0001). Coward et al. published a similar population based health administrative data study using data from eight provinces in Canada. In this study the national incidence of IBD was estimated to be 29.9 per 100,000 (95% PI 28.3-31.5) in 2023.ll The incidence of IBD in pediatric patients was found to be increasing (average annual percentage change (AAPC) 1.27%; 95% CI 0.82-1.67). The prevalence of IBD was 843 per 100,000 (95% PI 716-735) in 2023 with forecasted increases (AAPC 2.43%;95% CI 2.32-2.54). In pediatric patients the prevalence in 2023 was 82 (95% PI 77-88) and the forecasted AAPC was 1.91 (1.46-2.31). According to the 2023 Impact of IBD in Canada Report by Crohn’s and Colitis Canada, an estimated 322,600 Canadians are living with IBD, with 11,000 new diagnoses expected in 2023. The global incidence and prevalence of IBD has been rising. In 2011, Benchimol et al. published a systematic review detailing international trends in IBD. The review demonstrated a 60% increase in Crohn’s disease (CD) and a 20% increase in ulcerative colitis (UC) across both developing and developed countries. Benchimol et al. also published the results of a health administrative data analysis evaluating children with a diagnosis of IBD between 1999-2010 across five Canadian provinces, which together account for 79.2% of the Canadian population. They reported that incidence of IBD in children aged five and under increased during the study period (annual percentage increase [APC] +7.19%; 95% CI, +2.82% to +11.56%). The prevalence of IBD also increased significantly during the study period (APC+4.56%; 95% CI, +3.71% to +5.42%).
Copyright (c) 2024 Canadian IBD Today https://creativecommons.org/licenses/by-nc-nd/4.0
S1PR Modulators in the Management of Ulcerative Colitis: Considerations for Practice
Sphingosine-1-phosphate receptor (S1PR) modulators are novel oral small-molecule therapies that offer a unique profile compared to other advanced therapies in the treatment of ulcerative colitis (UC), including oral administration, linear pharmacokinetic profiles, reduced immunogenicity, and lower costs associated with manufacturing. The activation of S1P G-protein coupled receptors plays an inflammatory role in UC by promoting lymphocyte egress from lymphoid organs into circulation and colonic mucosa. S1PR modulators lead to internalization and degradation of these receptors, thereby reducing inflammation. Ozanimod was the first S1PR modulator approved for treating moderately-to-severely active UC and is also approved for multiple sclerosis. More recently, a second agent, etrasimod, was approved for UC. Etrasimod acts on different S1PR subtypes to avoid off target vascular and cardiac effects, has no up-titration regimen during initiation, a shorter half-life and less propensity for drug interactions. This review summarizes clinical trial and real-world data and provides guidance on the clinical uses of S1PR modulators.
Recent Advances in Complementary and Alternative Therapies for Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) is a chronic relapsing-remitting inflammatory condition of the gastrointestinal (GI) tract, primarily comprised of 2 major types: Crohn's disease (CD) and ulcerative colitis (UC). The pathogenesis of IBD is not fully elucidated but is thought to be multifactorial involving genetic, environmental, and immunological contributors. The incidence of IBD has been rising worldwide, particularly in developed nations. Canada, in particular, has one of the highest prevalence rates of IBD globally, with recent data indicating that over 320,000 Canadians are living with IBD, making it a significant public health concern. The chronic nature of IBD, along with the severity of its symptoms, and the adverse effects occasionally attributed to management (e.g. immunosuppression, corticosteroids, surgical complications) can significantly reduce the quality of life for those affected. As such, many patients with IBD use complementary and alternative medicine (CAM) due to safety concerns of conventional therapy and a sense of greater control over their disease. CAM refers to a broad range of healthcare practices, such as herbal medicine, acupuncture, homeopathy, fecal microbiota transplants, and probiotics, which are not typically considered part of conventional western medicine. The use of CAM among patients with IBD is high, with current or past use of CAM ranging from 21-60% of IBD patients. Given the propensity of patients with IBD to seek CAM and the unfamiliarity that many medical practitioners have with the evidence of benefit/harm from these practices, this review seeks to summarize recent advances in clinical research on CAM use for IBD.
Management of Anemia in Inflammatory Bowel Disease
Anemia is one of the most common complications of inflammatory bowel disease (IBD), with estimates of its prevalence varying from 9-74%. It is estimated to affect more than 1.2 billion people worldwide and evidence suggests that the incidence of anemia in people with IBD is almost double that of people without IBD (92.75 people with IBD per 1000 person-years vs 51.18 without IBD per 1000 person-years). Having a thorough approach to anemia in IBD is important because it is common and potentially dangerous, and because of its potential to arise from multiple different pathological and/or physiological processes.
Can Non-invasive Monitoring Replace Ileocolonoscopy for Postoperative Recurrence of Crohn’s Disease?
The therapeutic landscape for Crohn’s disease (CD) has been reshaped by improvements in disease management and medical therapy, leading to a decrease in the necessity for intestinal resection. However, surgical intervention still plays a crucial role in treating medically refractory disease or complications such as strictures or fistulae. Recent biologic-era population studies have shown that the rate of CD-related abdominal surgery over 10 years is up to 49.9% in adult-onset CD and 37.7% in pediatric onset CD.
The Role Of Upfront Surgery in the Management of Ileal Crohn’s Disease
Crohn's disease (CD) is a chronic inflammatory disorder characterized by transmural inflammation that can affect any part of the gastrointestinal tract. Among the various phenotypes of CD, involvement of the terminal ileum, known as ileal CD, poses unique challenges in management due to its potential for complications such as strictures, fistulas, and abscesses. While medical therapy remains a cornerstone in the management of CD, the role of surgery, particularly upfront surgical intervention (early resection), has garnered increasing attention in recent years. The decision to pursue surgical intervention at the outset of disease management, rather than relying solely on medical therapy, is a subject of ongoing debate in the field. Upfront surgery (prior to advanced medical therapies) may offer benefits such as rapid resolution of symptoms, avoidance of long-term immunosuppressive therapy and prevention of disease progression. However, concerns regarding the postoperative morbidity and potential for recurrence associated with surgical intervention warrant careful consideration.
Acute Severe Ulcerative Colitis: Review of Management and Emerging Treatments
Acute severe ulcerative colitis (ASUC) is a medical emergency, with an overall mortality rate of 1%. Patients with ulcerative colitis (UC) have a 20–25% rate of severe exacerbation requiring hospitalization for urgent medical treatment and surgical consideration. The rate of re-hospitalization for recurrent ASUC is 34.4%, and it typically occurs within 24 months of the index admission. Treatment requires a patient-centred multidisciplinary approach that includes gastroenterology, colorectal surgery, and nutrition support, with the goal of minimizing disease complications, adverse events of treatment, and healthcare costs.6 Clinicians and patients have an increasing number of treatment options and additional safety issues to consider. We review the current approach to management and summarize emerging data on the use of novel agents to treat ASUC.
Treatment Related Adverse Events and Monitoring of Patients Receiving Biologic or Small Molecule Therapy for Inflammatory Bowel Disease
The management of Inflammatory Bowel Disease (IBD) has evolved with the emergence of new treatment paradigms and the introduction of novel advanced therapies, including monoclonal antibodies (mAbs) and small molecules. These advanced therapies have improved disease control, but they necessitate careful pre-treatment assessment and ongoing monitoring to manage potential adverse effects and optimize patient outcomes. This review focuses on practical approaches to treatment-specific monitoring of currently available advanced therapies.
Medical Management of Inflammatory Bowel Disease in the Elderly
The optimal management of inflammatory bowel disease (IBD) can be challenging at the best of times; however, this notion becomes more salient when treating the niche population of elderly IBD. The prevalence of IBD in elderly Canadians has almost doubled in a span of 5 years, increasing from 1/160 in 2018 to 1/88 in 2023. While the majority of IBD patients are diagnosed between 20-40 years of age, 10-15% are diagnosed at >60 years of age. Elderly-onset ulcerative colitis (UC) patients more commonly have left-sided colitis with less disease extension whereas elderly-onset Crohn’s disease (CD) patients typically exhibit an inflammatory colonic phenotype. Although elderly-onset IBD patients typically demonstrate a less aggressive natural history overall, they have a similar risk of surgery compared to their adult-onset IBD counterparts with the majority being treated with non-advanced therapies. A lack of physician knowledge and comfort level in treating elderly IBD likely contribute to patients being maintained inappropriately on long-term steroids and/or 5-aminosalicylates. The existing literature on elderly IBD often fails to differentiate between aging pediatric or adult-onset IBD patients and elderly-onset IBD patients; therefore, this article will discuss the management of both groups together. Nevertheless, it is important to note that these two groups likely have different underlying pathophysiological mechanisms driving their respective diseases which can have implications for therapeutic decisions. Unfortunately, the majority of evidence to help guide decision-making in elderly IBD is derived from retrospective analyses of real-world data or health administrative datasets, as well as post-hoc analyses of randomized controlled trials (RCTs). Drug efficacy aside, nuanced care of the elderly IBD patient involves an appreciation of frailty and comorbidity to help contextualize the risks of immunosuppressive therapy. Not only is the safety of therapies contingent upon the intrinsic immunosuppressive properties of the drug, but in addition, drug efficacy needs to be considered with respect to the effectiveness in controlling disease activity and achieving corticosteroid-free remission.
Ophthalmic Complications in Inflammatory Bowel Disease
The prevalence of inflammatory bowel disease (IBD), estimated at 843 per 100,000 people (95% PI 828-859) (i.e., 0.843% of the population) in 2023 is increasing in Canada and is expected to reach 1.1% of the Canadian population by 2035. Consequently, extraintestinal manifestations and complications will also increase. Up to 50% of patients suffering from IBD will develop an extraintestinal manifestation (EIM) during the course of their disease, patients with Crohn’s disease (CD) being more often affected then those with ulcerative colitis (UC). Ocular manifestations are the third most common EIM after articular and dermatological involvements. Ocular complaints in patients with IBD can represent an EIM, a complication of systemic treatment or an unrelated affection. All patients presenting with a red eye, light sensitivity, loss of vision or any acute ocular symptom(s) should be promptly evaluated by an eye specialist. Early detection of ophthalmologic diseases and appropriate management require collaboration between specialists and are of utmost importance to avoid permanent visual loss. The most common ocular manifestations reported in IBD patients are episcleritis (2-5%) and anterior uveitis (0.5-3.5%). Other less common manifestations include scleritis, intermediate and posterior uveitis, retinal vasculitis, retinal vascular occlusions, orbital inflammatory syndrome, and optic neuritis. Ocular manifestations can also be associated with malabsorption syndromes encountered in some patients with IBD. Secondary vitamin A deficiency can result in night blindness and keratoconjunctivitis sicca.
Upadacitinib for Crohn’s Disease: An alternative to anti-TNF Therapy?
Since its approval for Crohn's disease, following the successful U-EXCEL, U-EXCEED, and U-ENDURE Phase 3 trials, upadacitinib has been increasingly prescribed to Crohn's disease patients, including both biologic-naïve and biologic-experienced individuals. Although there are numerous clinical scenarios where this option is worth considering, it can be viewed as a highly reasonable alternative to anti-TNF therapy for Crohn's disease.