DAY 3: Recent Guideline Updates for IBD Clinical Care

Edward L. Barnes, MD, MPH, FACG, from University of North Carolina at Chapel Hill School of Medicine, reviewed the 2025 updates for Ulcerative Colitis (UC) management. He noted that since the last guidelines were published, the number of treatment options has increased, making management of UC highly complex. Some key points highlighted from the new guidelines included:

• The overall treatment goal is steroid-free remission with biological response indicated by biomarkers or endoscopic improvement
• The extent of bowel involvement is less important than the severity of the disease and evaluation of short and long term prognosis for each patient
• Biosimilars are acceptable substitutes for originator therapies
• Colectomy is an option for patients with moderate to severe active UC who are refractory or intolerant to maximal medical therapy
• The Ulcerative Colitis Index was updated 
• Poor prognosis factors include age <40 years, extensive colitis, severe disease, (Mayo endoscopy score of 3, UC endoscopic index of severity of at least 7), hospitalization for UC, elevated CRP, and low serum albumin
• For mild to moderate UC, oral and topical 5-ASA therapy is recommended for left-sided disease, once daily oral 5-ASA is recommended for any extent to reduce patient burden, and topical 5-ASA is recommended for mildly active proctitis
• For moderate to severe UC

1. A table rates the strength and quality of evidence for available therapies, without ranking
2. Patients do not need to continue 5-ASA when using an advanced therapy or after failing on an advanced therapy
3. For responders to anti-TNF who are starting to lose response, serum drug levels and antibodies can distinguish between primary and secondary non-response
4. Vedolizumab is recommended over adalimumab for induction and maintenance of remission based on data from the only head-to-head trial (VARSITY)
5. Patients should have access to all available medications
6. For patients with higher risk of infection complications, vedolizumab or anti-IL-23 therapies are preferred over anti-TNF or JAK inhibitors
7. The presence of extraintestinal manifestations (EIMs) may aid in treatment selection

•  For hospitalized patients with acute severe UC, the new guidelines include a stepwise algorithm that may be helpful for trainees

Anita Afzali, MD, MPH, MHCM, FACG, from University of Cincinnati College of Medicine, discussed the 2025 guidelines updates for Crohn's disease (CD) care. The guidelines were last updated in 2018, and the 2025 guideline is now a living document that will be updated every year. The guidelines recognize that clinical judgement is important for providing individualized care. Dr. Afzali provided some highlights, including

• Incorporation of intestinal ultrasound (IUS) and a fecal calprotectin (FCP) cutoff of 50-100 µg/g to distinguish inflammatory disease and track response to therapy
• Evidence does not support routine genetic testing and serologic marker testing
• Early treatment is essential to shift the natural history of CD and slow progression
• NSAIDs, cigarette smoking, stress, depression, and anxiety modify CD risk
• There is a need to differentiate between activity and severity, and patient workup should estimate the risk of rapid progression
• Incorporation of STRIDE-II recommendations for proactive monitoring of disease with clear stepwise goals
• Based on the CALM study, a recommendation to use a combination of objective biomarkers and subjective markers of healing in active monitoring
• Based on the PROFILE study, treatment should focus on early appropriate therapy for each patient, including first-line use of advanced therapies 
• Failure of conventional therapy should not be the threshold for initiation of advanced therapy for CD 
• In mild to moderate CD, a recommendation against oral mesalamine for initiation or maintenance; budesonide can be used for induction but not maintenance; 5-ASA is recommended
• For moderate to severe CD, a table of therapies recommends use for induction and/or maintenance based on evidence from large clinical trials and a few head-to-head studies
• Based on LIRIC, surgery is an appropriate primary treatment in certain patients with a small defined area of non-stricturing ileocecal CD
• Infliximab is recommended for fistulizing/perianal disease and post-ileocolonic resection, followed by colonoscopy 6-12 months later

Fernando S. Velayos, MD, MPH, Director, Regional Program for Inflammatory Bowel Disease, Northern California Kaiser Permanente discussed the development of new guidelines for dysplasia and IBD. He noted that the risk of CRC in IBD has improved over time but patients with IBD have a 50% higher incidence of CRC and 2-fold increased mortality compared to the general population. High-definition endoscopy has improved detection, and chromoendoscopy with dye spray may help identify early disease that could be overlooked. The signs of dysplasia are subtle, with atypical mucosal color, vascularity, nodularity, elevation, and ulceration, and careful endoscopy is essential. Biopsy should be limited to certain high-risk patients, such as those with prior sclerosing cholangitis, prior neoplasia, active inflammation, or tubular scarred colon.