DAY 1: Monitoring Strategies in the Treatment of Inflammatory Bowel Disease

Jill K Gaidos, MD, FACG, from Yale School of Medicine, described a treat-to-target paradigm for initiating IBD therapy, based on the STRIDE-II treatment goals for IBD (Turner et al, 2021). These goals move through a series of short- to long-term targets, starting with symptomatic response and remission, decrease in calprotectin, and endoscopic evidence of healing with normalization of quality of life without disability. Transmural healing in Crohn’s disease (CD) and histological healing in ulcerative colitis (UC) can be considered as additional treatment targets, achieved using a steroid-free treatment regimen.
Dr. Gaidos described a window of opportunity after diagnosis where selection of the appropriate initial treatment can potentially change the natural history of the disease. Treatment selection takes into account the risk of complications related to disease activity (patient-reported outcomes and inflammatory burden) and the presence of risk factors for a more severe prognosis (Lichtenstein et al, 2025; Rubin et al, 2025). Top-down approaches that start with advanced therapies have been shown to be more effective and as safe as step-up approaches that start with steroids and introduce advanced therapies sequentially in response to flare-ups (Noor et al, 2024; Dai et al, 2023). She suggested that CRP and fecal calprotectin (FCP) be measured at baseline and that proactive disease monitoring is scheduled every 2-3 months, regardless of disease activity (Plevris & Lees, 2022). Timing of clinical response assessment will vary based on the treatment used, but usually occurs between 6 and 12 weeks. Symptoms of IBD do not always correlate with inflammation, so objective measures should be used to assess clinical remission at 3-6 months. These may include biomarkers (CRP, FCP) and intestinal ultrasound at the bedside. For assessing endoscopic remission (6-12 months), the decision to conduct repeat endoscopy is based on a combination of the severity of clinical symptoms, inflammatory biomarker levels, and patient preference. She recommended use of objective endoscopy scoring, such as SES-CD or Mayo for UC. Proactive monitoring should continue every 6-12 months after endoscopic remission is achieved. If any of the treatment goals are not met, the series is restarted with a change in therapy.

Erica R. Cohen, MD, from Capital Digestive Care, discussed considerations when de-escalating therapy in IBD. Medical factors (long-term risk and benefit), patient preferences, quality of life considerations, and external factors such as cost of care and healthcare resource utilization are considered. Planning for de-escalation first requires confirmation of remission, a discussion of the risks and the monitoring plan, and identification of available rescue medications. Dr. Cohen reviewed the published literature on de-escalation of thiopurine monotherapy and anti-TNF plus thiopurine. Data on the de-escalation of advanced IBD therapies is limited. Clinical remission while on thiopurine monotherapy is an insufficiently robust endpoint to inform de-escalation, particularly in patients with more active disease. It is advisable to overlap with an alternative treatment before cessation of thiopurine. Monitoring for CRP and fecal calprotectin can detect signs of early relapse after de-escalation or withdrawal. For patients on a combination anti-TNF and thiopurine, mucosal healing and steroid-free remission for at least 1 year should be confirmed before de-escalating the immunomodulator. Anti-TNF levels are checked before tapering or stopping the immunomodulator, then rechecked every 3 to 6 months; imaging or colonoscopy is performed after 6-12 months. Several studies have documented the option to restart anti-TNF after a “drug holiday” of at least 6 months; Dr. Cohen advised checking anti-TNF drug trough levels 3-5 days after first dose to determine next steps. It is important to discuss and document the monitoring strategy, including serial labs, calprotectin, and drug levels, as well as the timing of colonoscopy, and to document the rescue strategy, which may involve restarting a prior medication or moving on to the next treatment option.

Posters of interest:
Oscar Noble, MD, from Houston Methodist Hospital, presented his work on the feasibility of intestinal ultrasound in pregnant patients with IBD. Intestinal ultrasound is a non-invasive option for assessing IBD markers in pregnancy, and can be used to measure bowel wall thickness, vascularity, bowel wall stratification, and mesenteric fat; however, previous studies have reported reduced sensitivity and visualization of the rectum, sigmoid colon, and terminal ilium with increasing gestational age. In a retrospective study of 40 intestinal ultrasound scans of pregnant patients with IBD (60% CD, 37.5% UC; 57% in second trimester), Dr. Noble and colleagues found that disease in previously known locations was visualized in 95% of scans, and the visualization rate per segment, from the descending colon to terminal ileum, was 100%. The visualization rate of sigmoid colon was 98%, rectum was 87%, and proximal small bowel was 85%. Eleven scans had limitations in visualizing at least one segment, with a significant association between proximal small bowel limitations and trimester (p=0.015). (P1195)

Ashujot K. Dang, MD, from University of California Riverside School of Medicine, presented data from a real-world comparative outcomes study of  intestinal ultrasound versus colonoscopy in monitoring IBD. They identified 806 adult patients with CD or UC in the TriNetX Collaborative Network who underwent either intestinal ultrasound or colonoscopy. The cohorts were matched on demographics, comorbidities, and baseline medications. Patients who underwent intestinal ultrasound had a significantly lower risk of biologic therapy escalation and experienced fewer flares than those who underwent colonoscopy; however, they also were more likely to be taking corticosteroids and have an obstruction or stricture. The advantages of intestinal ultrasound may be due to the ability to directly visualize bowel wall inflammation in real-time, allowing for earlier therapeutic adjustment. (P3184)x
Dr. Dang also reported on trends in intestinal ultrasound utilization for IBD using data from TriNetX for all adult patients with IBD between 2017 and 2024 who were treated in academic centers (n=488,673) and non-academic centers (n=196,051). Her group found that the use of intestinal ultrasound has increased in both settings, but at a faster pace in academic centers (1.90% to 3.03%) than in non-academic centers (1.75% to 2.76%) over the 8-year period. Intestinal ultrasound use was more frequent with Hispanic and female patients. (P3185)