Canadian IBD Today

The 5 Most Clinically Impactful Papers Published in 2024 and Beyond

Laura E. Targownik — 2025-06-23

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.

Using Immunosuppressive Therapies to Treat Inflammatory Bowel Diseases (IBD) in the Post‑Cancer Setting

Rana Kandel — 2025-06-23

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.

Inflammatory Bowel Disease in the Elderly

Seth R. Shaffer — 2025-06-23

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.

Obesity in Inflammatory Bowel Disease (IBD): Recognizing a Critical Modifier In Modern Disease Management

Joëlle St-Pierre — 2025-06-23

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.

Is There Still a Role for Proactive Therapeutic Drug Monitoring (TDM) in Inflammatory Bowel Disease (IBD): A Review of the Literature

Davide De Marco — 2025-06-23

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.