Am J Gastroenterol. 2025 Feb 1;120(2):420-430. doi: 10.14309/ajg.0000000000002964.Epub 2024 Jul 15.

Hannah K Systrom ¹, Victoria Rai ², Siddharth Singh ³, Leonard Baidoo ⁴, Adam S Cheifetz ⁵, Shane M Devlin ⁶, Krisztina B Gecse ⁷, Peter M Irving ⁸, Gilaad G Kaplan ⁶, Patricia L Kozuch ⁹, Thomas Ullman ¹⁰, Miles P Sparrow ¹¹, Gil Y Melmed ¹², Corey A Siegel ¹

Author information

¹Dartmouth Hitchcock Medical Center, Division of Gastroenterology and Hepatology, Lebanon, New Hampshire USA.

²Yale School of Medicine, New Haven, Connecticut USA.

³University of California San Diego, Division of Gastroenterology, San Diego, California USA.

⁴University of Tennessee College of Medicine, Inflammatory Bowel Disease Center, Memphis, Tennessee USA.

⁵Beth Israel Deaconess Medical Center, Inflammatory Bowel Disease Center, Boston, Massachusetts, USA.

⁶University of Calgary, Inflammatory Bowel Disease Centre, Calgary, Alberta, Canada.

⁷Amsterdam University Medical Center, Gastroenterology, Amsterdam, Netherlands.

⁸Guy's and St. Thomas' Hospitals, Gastroenterology, London, United Kingdom.

⁹Jefferson University, Division of Gastroenterology, Philadelphia, Pennsylvania, US.

¹⁰Montefiore Medical Center, Division of Gastroenterology, Bronx, New York, USA.

¹¹The Alfred Hospital, IBD Unit, Melbourne, Victoria, Australia.

¹²Cedars-Sinai Medical Center, Inflammatory Bowel Disease Center, Los Angeles, California USA .

Abstract

Background: A treat-to-target strategy for inflammatory bowel disease (IBD) recommends iterative treatment adjustments to achieve clinical and endoscopic remission. In asymptomatic patients with ongoing endoscopic activity, the risk/benefit balance of this approach is unclear, particularly with prior exposure to advanced therapies.

Methods: Using the RAND/University of California Los Angeles Appropriateness Method, 9 IBD specialists rated appropriateness of changing therapy in 126 scenarios of asymptomatic patients with ulcerative colitis and Crohn's disease and active endoscopic disease. Disease extent and behavior, prior treatment, prior complications, and recent disease progression were considered, as were factors that might influence decision-making, including age and pregnancy. Ratings were collected through anonymous survey, discussed at an in-person meeting, and finalized in a second anonymous survey.

Results: Panelists rated change in therapy as appropriate (i.e., expected benefit sufficiently outweighs potential harms from continuing therapy) in 96/126 scenarios, generally in patients with progressive, complicated, and/or extensive disease, while changing therapy was rated uncertain in 27 scenarios of mild and/or stable disease. Changing therapy was rated inappropriate in ulcerative colitis patients with mild and stable disease previously exposed to ≥3 therapies or with improved endoscopic activity, and in Crohn's disease patients with only scattered aphthous ulcers. The validated threshold for disagreement was not crossed for any scenario. Patient age older than 65 years and a plan for pregnancy in the next year might influence decision-making in some settings.

Discussion: Appropriateness ratings can help guide clinical decision-making about changing therapy to achieve endoscopic remission in asymptomatic patients with IBD until data from ongoing randomized studies are available.