Optimising care and dealing with complications in IBD

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Reference: September 2025 | Issue 9 | Vol 11 | Page 30

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How to optimise care for inflammatory bowel disease (IBD), from management to complications, was the focus of a dedicated two-speaker session during the Irish Society of Gastroenterology (ISG) Winter Meeting in November 2024.

Prof Johan Burisch, Consultant Gastroenterologist at Copenhagen University Hospital, Hvidovre, Denmark, gave a detailed presentation on the management of ulcerative colitis (UC) flare in patients with mild to moderate disease.

During his talk, Prof Burisch emphasised the need to “get the most out of established treatments for UC before we move on to newer therapies”, focusing on the use of 5-aminosalicylate (5-ASA) therapy specifically.

He outlined evidence-based strategies to consider for optimisation of 5-ASA therapy in UC patients, with key elements including individual dosing, treatment duration, adherence, and topical therapy.¹

Dose optimisation

“Of course, the first thing is to choose the right dose for the right patient,” Prof Burisch said, citing a 2019 American Gastroenterological Association (AGA) technical review of data on different induction doses of 5-ASA (≥2g vs <2g) and the induction of remission.²

“What it shows basically is if you choose any dose above 2g, this is better than choosing low-dose mesalazine. It is also what is summarised in most guidelines around the world.”

Furthermore, doses over 3g have also been shown to have superior efficacy compared to low doses (<2g).² Prof Burisch cited further data from the review, which showed mesalazine doses over 3g/day (relative risk (RR) 0.81; 95% confidence intervals (CI) 95 0.71-0.92) and 2-3g/day (RR 0.88; 95% CI 0.79-0.99) were superior to doses of less than 2g/day of mesalazine for induction of remission, with low heterogeneity.*

He then cited data from the randomised, double-blind, controlled ASCEND II and ASCEND III trials which assessed the efficacy of 4.8g/day vs 2.4g/day of mesalazine in adults with active UC, confirming the efficacy of higher doses in different subgroups, including those who had tried other treatments.^3,4

As well as optimising the initiation dosage, the right maintenance dose is also very important in 5-ASA treatment for UC, Prof Burisch said. The standard optimum dose for maintaining remission is between 2-3g/day of mesalazine, he said, quoting a systemic review and meta-analysis of trial data supporting this approach.⁵

He also quoted a Japanese study looking at 527 patients with UC who achieved remission on 4.8g/d 5-ASA treatment and what happened when they were switched to maintenance dosing (>3g/d vs <3g/d).⁶

“This is again something we need to consider when dealing with our patients. If it was difficult to get them into remission and we used higher doses, maybe we should keep them on higher doses for a longer time before going down in dosage,” he said, highlighting the importance of stratifying patients appropriately.

He quoted another study which showed a reduction in the risk of flares with high-dose mesalazine compared to low-dose mesalazine in UC patients with low adherence, “which is something we should consider in clinical practice when dealing with patients with low adherence”.⁷

Prof Burisch next discussed the role of topical therapy for induction of remission in UC and for the prevention of relapse.^8,9

“Combination of topical and oral mesalazine for maintenance of remission is better than low-dose oral mesalazine, as has been shown in several studies,” he said, summarising the findings.

FIGURE 1: Comprehensive diagnostic and management algorithm of CDI in IBD. Adapted from Dalal RS, et al. Curr Opin Gastroenterol. 2021 Jul 1;37(4):336-343.

Adherence

Medication adherence is a key issue to ensuring the best outcomes for UC patients on 5-ASA therapy, Prof Burisch emphasised.

Research has shown that non-adherent patients have up to five times higher risk of relapse than those who take their medicine regularly, he said.^10,11

Prof Burisch cited data which showed an overall 79 per cent rate of non-adherence with any 5-ASA after one year, with a substantial decrease in 5-ASA therapy adherence after just 30 days.¹² “This is something all of us who see these patients are familiar with,” he remarked.

If patients are not taking their medication as prescribed, then drug effectiveness will obviously be impacted and the clinician may think it is not working for them and switch to another treatment unnecessarily, Prof Burisch stressed.

“We really need to address this issue. If you don’t address it and you do not have a good enough relationship with your patient where they feel comfortable enough to admit that they are not taking their medication, it makes it difficult to make the right decisions. You might move on [to a different medication] for the wrong reasons,” Prof Burisch said.

In this regard, research also confirms the importance of consulting with patients about drug formulation and dosage frequency preferences to try to maximise adherence, he said.¹³

“Trial data shows that those patients who have a good understanding of their disease and a good relationship with their physician have better adherence,” Prof Burisch stated.¹⁴

Clostridium difficile

Also at the ISG Winter Meeting, Dr Tee Keat Teoh, Consultant Microbiologist, Public Health Laboratory Dublin and St James’s Hospital, addressed the risk of Clostridium difficile infection (CDI) in IBD.

He reminded the meeting that CDI is the leading cause of hospital-acquired infectious diarrhoea in adults, and is associated with significant morbidity, mortality, and costs.^15,16,17 CDI can lead to complications like severe colitis, toxic megacolon, and death.¹⁵

CDI normally develops in people who are already vulnerable, with key risk factors including previous antibiotic exposure, older age, a weakened immune system, recent hospital or nursing home admission, and previous history of CDI, Dr Teoh outlined.¹⁸

The literature shows that IBD patients have a five times increased risk of CDI compared to the general population. IBD patients also tend to do worse and have a significantly increased risk of recurrent CDI risk, especially in those aged below 50, he noted.¹⁹

Specifically, there is an increased incidence of CDI in UC, compared to Crohn’s disease.¹⁹ Colonic dysbiosis from colitis impairs resistance to bacterial colonisation, and immunosuppression may impair immune response to CDI,” he said, adding that about 8 per cent of IBD patients have asymptomatic toxigenic C difficile.²⁰

Diagnosis of CDI in IBD patients is difficult, largely due to the symptom overlap of both conditions, and they also present differently (younger age, more often community onset, antibiotic exposure less likely), Dr Teoh said.^19,21

Furthermore, CDI in IBD patients can lead to subsequent IBD flares, escalation of treatment, and poorer patient outcomes.²¹

Currently there is no international consensus guidance for specifically managing IBD patients with CDI, De Teoh explained.

General European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidance on managing CDI recommends fidaxomicin for first-line use in all patients with CDI, he noted.²² Metronidazole is no longer recommended as a first-line agent for CDI treatment by the aforementioned bodies in their latest guidance.

Dr Teoh also discussed the use of other treatments for CDI in IBD patients, including faecal microbiota transplant which, while shown to be safe and effective, is not yet easily accessible in Ireland.²³

In relation to prescribing IBD immunosuppressives during CDI diagnosis, Dr Teoh noted that the literature is sparse but an AGA practice review says the decision should be individualised, but is positive towards continuation in uncomplicated CDI.²¹

Concluding his talk, Dr Teoh recommended using a detailed algorithm for the diagnosis and treatment of CDI in IBD, published in Current Opinion in Gastroenterology in 2021.¹⁹

*Not all mesalazine preparations are licensed for doses >3g/day for inducing remission. Please check individual product SmPCs.