Managing inflammatory bowel disease has never been more complex, or more promising. The rapid expansion of available biologics and small molecules over the past decade has transformed what was once a limited toolkit into a sophisticated array of options. But with that abundance comes the challenge of using it wisely.
Therapeutic Sequencing: Being Thoughtful, Not Just Thorough
Years ago, the decision-making was simpler. In the beginning, there was only one biologic option. Today, we have multiple other classes of biologics: IL-23 inhibitors, integrin inhibitors, JAK inhibitors, and more. That's a tremendous advancement for our patients, but it also demands that we be far more deliberate about the order in which we use these therapies.
Sequencing matters more than many clinicians realize. Certain biologics, for example, perform significantly better as a first-line therapy than they do after a patient has already failed other agents. Conversely, patients who have failed TNF inhibitors are notoriously difficult to manage, and subsequent therapies often lose effectiveness in that setting. This isn't just academic: choosing a medication without considering where it fits in the treatment sequence can meaningfully reduce a patient's long-term options and outcome. The evidence increasingly supports positioning agents strategically rather than defaulting to familiar choices or simply accommodating patient preferences without clinical justification.
This means regularly asking ourselves not just which medication, but when, and what comes next if this one fails.
Biomarkers: Moving Beyond Symptoms
One of the most important cultural shifts in IBD management has been moving away from symptom-based endpoints toward objective disease assessment. It's not enough for a patient to feel better. We now know that symptoms and mucosal inflammation don't always correlate. Patients can feel well with significant ongoing damage, and others can feel terrible despite no detectable inflammation.
The standard of care today requires confirming endoscopic remission, typically via colonoscopy in 6 to 12 months after initiating or changing a therapy. But colonoscopy alone isn't sufficient for monitoring. Fecal calprotectin has become an essential tool in the treat-to-target framework, providing a reliable, noninvasive measure of intestinal inflammation that we can check at three months to assess early treatment response and allow us to proactively adjust therapy. Elevated calprotectin values signal the need for closer follow-up and can guide decisions before a full endoscopic evaluation is warranted.
Emerging tools like intestinal ultrasound are also gaining traction at various centers, offering point-of-care assessment of disease activity. As access and training expand, these modalities will play an increasing role in objective monitoring.
Patient Engagement: Knowledge vs. Understanding
Today's IBD patients often arrive having done substantial research, and I'd argue that's mostly a good thing. An informed patient is an engaged patient. Where it becomes complicated is when online information, whether from AI or a disease forum, leads to requests that don't align with a patient's clinical reality. A patient new to IBD asking about Skyrizi or Tremfya is having a reasonable conversation. A patient who has failed multiple biologics asking to try vedolizumab requires a different kind of discussion.
The physician's role is to meet patients where they are: validate their curiosity, correct misinformation without dismissing it, and explain the clinical rationale behind treatment decisions. When a patient's preference is reasonable and the data doesn't strongly favor one agent over another, I'm generally open to accommodating it. When it doesn't make clinical sense, that's an opportunity to educate.
What sets providing excellent IBD care apart ultimately comes down to this: staying current, being thoughtful and systematic, and never letting symptom control be the only measure of success.
Author
Adam Gluskin, MD, is a gastroenterologist with GI Alliance of Illinois - Arlington Heights.