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Keeping up in IBD FAQ
Are You Keeping Up in IBD? Experts Answer Your Frequently Asked Questions

Released: July 16, 2026

Jordan E. Axelrad
Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF
Jami Kinnucan
Jami Kinnucan, MD, AGAF, FACG, FCCF
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Key Takeaways
  • HCPs should use an objective measure of inflammation to guide treatment decisions regardless of patients’ symptom burden.
  • De-escalating therapy in IBD does not always equal treatment cessation; HCPs can use de-escalation strategies to switch patients to a different, more effective therapy.
  • Drug manufacturers often provide assistance programs that can help patients access the therapies they need, and AI can help HCPs write letters of medical necessity to appeal denials.

In this commentary, Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF, and Jami A. Kinnucan, MD, AGAF, FACG, FCCF, answer questions posed by healthcare professionals (HCPs) during a live symposium titled, “Are You Keeping Up in IBD? Leveraging the Latest Advances to Achieve Tight Disease Control” at APP Intensive: Gastroenterology 2026. Learn about specific considerations for de-escalating and switching treatment for patients with inflammatory bowel disease (IBD) as well as strategies advanced practice providers (APPs) can employ to improve their practice and patient outcomes.

When would you consider de-escalating therapy for patients with inflammatory bowel disease (IBD) in remission?

Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF:
That is a complicated question because we currently have very poor data to guide treatment de-escalation strategies. But the data do suggest that de-escalating therapy is not successful for most patients over time.

When considering treatment de-escalation, I ensure patients have had year after year of deep remission; normal radiography, colonoscopy, and biomarkers; and no symptoms. I would even go as far as to say patients should have normal biopsies, too. This way HCPs know that they are not setting patients up to see problems with normalization on the above factors, as described in the STRIDE II guidelines.

Jami A. Kinnucan, MD, AGAF, FACG, FCCF:
De-escalation does not always equal cessation of treatment. You could have a patient with ulcerative colitis who previously required escalation to advanced therapy with a biologic or small molecule agent. In the right patient who has achieved complete histologic normalization, is off corticosteroids, and does not have complications, de-escalation may be considered with discussion of risks and benefits. In doing so, HCPs should have conversations with patients about treatment de-escalation, especially if the choice is not driven by their preference but a medical requirement. But remember, de-escalation does not always have to be nothing; it could be “de-escalation” to a different therapy altogether.

What are the most common mistakes HCPs make when escalating or switching biologic therapies in IBD?

Jami A. Kinnucan, MD, AGAF, FACG, FCCF:
The number one mistake I see in practice is that some HCPs do not measure an objective assessment of inflammation in asymptomatic and symptomatic patients. The same can be true during treatment changes or adjustments, specifically regarding anti-TNF therapy. Furthermore, some HCPs do not use therapeutic drug monitoring to understand possible causes to suboptimal or loss of response or why patients may have active symptoms despite optimized treatment.

The common assumption is that only symptomatic patients have inflammation. But not all symptoms equal inflammation and not all inflammation equals symptoms. There are patients with IBD who have minimal to no symptoms but experience persistent subclinical inflammation and those who have significant symptoms without objective evidence of inflammation. The reality is that HCPs must focus the management of patients living with IBD on the right source to symptoms, considering both inflammatory and noninflammatory causes to symptoms.

Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF:
Keeping that in mind, APPs are first-line HCPs. In many practices worldwide, APPs are doing the heavy lifting of evaluating patients, enrolling them in the right studies, integrating the data from these studies into practice, and talking with patients about their next steps. Understanding exactly how to assess disease activity, having conversations with patients about their options, and wisely making treatment decisions based on patient preferences are all critical steps in the management of complicated IBD cases.

Today there are many options available when choosing the correct IBD therapy, but there are not so many that it is overwhelming. That allows us to have a good understanding of which therapies to think about for which patients and how to assess for treatment response vs partial and nonresponse.

Jami A. Kinnucan, MD, AGAF, FACG, FCCF:
That is an excellent point, and APPs or other HCPs should not be afraid to “phone a friend.” I have shared my cell phone number with many of the APPs practicing in my region, and they know when to ask me for help. This is important because patients with IBD are often not straightforward cases. Therefore, if any HCP feels uncomfortable or not confident with taking care of patients with IBD, there are other practices that will be more than happy to see these patients as a second opinion referral or to help you in terms of a partnership and/or comanagement of said patients. Do not feel like you cannot reach out and phone a friend.

Similarly, if the prescribing HCP is a community APP and not specialized in IBD, then reach out to a specialized HCP. They will be happy to see these patients, and they might be able to do so via telehealth, so patients are not required to travel somewhere new.

Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF:
Finally, it is important to address, especially for APPs working with prescribing HCPs who use more prednisone or mesalamine, inappropriate corticosteroid use now that we have many more effective and safe treatment options. Remember that the most unsafe things for patients with IBD are uncontrolled disease and unnecessary corticosteroid exposure, specifically prednisone. Whatever we can do as HCPs to mitigate these risks is critical.

You are seeing a patient with IBD who has a partial response to risankizumab. They are experiencing breakthrough symptoms 2 weeks leading up to the next dose, and their health insurance has denied 4-week dosing. Should you consider switching the patient’s treatment to another IL-23 inhibitor?

Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF:
This is a common scenario. Patients initiated on risankizumab who need their dose escalated may see their health insurance deny that request. Sometimes we are successful on an appeal, but that is not a guarantee. In this case, I would see if the manufacturer has an access program in cases of denial (ie, bridge program). Even if risankizumab is approved by the FDA to treat moderate to severe IBD but the 4-week dose does not fall under that indication, patients can potentially access it directly through the manufacturer. There may be assistance  programs available that can help patients gain access to their treatment if that is what their HCP wants them on.

Now, could we just move this patient over to guselkumab? Yes, this is an option that I certainly would consider. In particular, I would consider guselkumab if the patient wanted to stay on or had multiple indications for an IL-23 inhibitor.

Jami A. Kinnucan, MD, AGAF, FACG, FCCF:
That is excellent advice. Another strategy is to use OpenEvidence, an accessible AI tool dedicated to HCPs. It helps me write strong evidence-based letters of medical necessity. When asking for an off-label therapy, HCPs will generally need to include the patient's clinical data and a letter of medical necessity up front; otherwise, your request will be denied. By using OpenEvidence, HCPs can optimize their chances of getting an approval.

There are some other innovative AI programs out there. My practice is currently using one called TandemAI (now Forus), which has been great in terms of streamlining approval processes. I know it is a heavy lift, but I have seen peer to peer and letters of medical necessity be very successful with the support of these AI tools. We are seeing nearly 85% initial approval rate and an approximately 98% approval rate in our appeals because of some of these resources that we are using.

How can APPs collaborate with other HCPs to deliver comprehensive IBD care?

Jami A. Kinnucan, MD, AGAF, FACG, FCCF:
The first step is already being taken. Anybody who is reading this commentary has taken a step toward getting deeper education in this space. Then there are organizations like the Gastroenterology and Hepatology Advanced Practice Providers (GHAPP) that are ensuring sustained education across APP practice, knowing, too, that very few APPs are focused in IBD only.

Getting involved with regional and national conferences that are comprehensive in IBD care is another good step to take. You can also share the slideset from this program with your prescribing partner who may not be a specialist in IBD or not practicing evidence-based medicine. Maybe you can host a journal club where everyone gets up to date in IBD care by reading some of the newer studies. You also should find your “phone a friend.” Identify who you can connect with and who can help you comanage more complex patient cases. Just know that many of us in IBD are doing this already.

If you need assistance in finding your “phone a friend,” GHAPP has a network of different prescribing HCPs who are happy to partner with APPs in managing complex patient cases in the community.

Jordan E. Axelrad, MD, MPH, AGAF, FACG, FCCF:
It is also important to develop a therapeutic relationship with patients and the whole care team. APPs are crucial members of the care team, especially in complicated, multidisciplinary diseases like IBD. Patients with IBD do not just see their doctor and APP. There are nurses, pharmacists, psychologists, psychotherapists, psychiatrists, nutritionists, radiologists, rheumatologists, and dermatologists who all work with these patients. APPs are working across all those specialties.

The care team needs to work in symbiosis with all parts of this landscape. Everyone must work together to reach the ultimate goal of improving patients’ lives and taking care of them. So long as these goals are aligned, the information that we have provided in this commentary can better help APPs in their IBD management strategy.

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