Synopsis
Select and sequence advanced IBD therapies by phenotype, efficacy, safety and patient preference, with complete infection screening, early objective response assessment and class-specific toxicity management.
- Advanced IBD therapy includes anti-TNF, anti-integrin, interleukin-targeted biologics, Janus kinase inhibitors and sphingosine-1-phosphate modulators; licensed and NICE-funded choices change frequently.
- Choose from disease, location, fistulising or extra-intestinal phenotype, previous exposure, required speed, pregnancy plans, comorbidity, route, adherence and patient preference rather than a fixed universal ladder.
- Before treatment, confirm objective inflammation and screen tuberculosis, hepatitis and other relevant infection, vaccination status, malignancy history and class-specific cardiovascular or thrombotic risk.
- Anti-TNF therapy has strong experience in severe luminal and fistulising Crohn disease, but undrained abscess or uncontrolled infection must be treated before immunosuppression.
- Vedolizumab is gut-selective in mechanism, while ustekinumab and selective IL-23 therapies target cytokine pathways; onset and effectiveness vary by disease and previous drug exposure.
- Oral JAK inhibitors can act rapidly but MHRA class warnings require special caution in older people, smokers and those with cardiovascular, malignancy, venous-thromboembolism or serious infection risk.
- Primary non-response, pharmacokinetic loss, immunogenicity and mechanistic failure need different responses; therapeutic drug monitoring is most established for anti-TNF medicines.
- Do not continue expensive or hazardous treatment without an agreed objective induction endpoint, maintenance monitoring and a plan for infection, surgery, pregnancy and vaccination.
Key red flags
Never start or continue an advanced immune therapy through uncontrolled sepsis, untreated active tuberculosis, major opportunistic infection or an undrained Crohn abscess.
Acute dyspnoea, pleuritic pain, leg swelling, myocardial or neurological symptoms on a JAK inhibitor needs emergency thrombotic and cardiovascular assessment.
Disseminated shingles, severe primary varicella or neurological infection in an immunosuppressed patient requires urgent antiviral and specialist management.
New jaundice or marked transaminitis may represent viral hepatitis reactivation, drug injury or another hepatobiliary emergency and should not wait for routine infusion review.
Anaphylaxis during infusion requires immediate emergency treatment; do not simply slow the infusion and continue without severity assessment.
Investigation priorities
Confirm that active inflammation justifies escalation and provide a response baseline.
Management branches
Moderate to severe objective IBD activity needs advanced steroid-sparing therapy.
- Confirm diagnosis, inflammatory target, luminal versus fistulising phenotype, previous drug response, need for speed and whether surgery or drainage better addresses structural disease.
- Screen infection, vaccination, malignancy, cardiovascular and thrombosis risk, organ function, pregnancy plans and medicine interactions before narrowing the class choice.
- Compare current NICE-funded efficacy, safety, route, monitoring, extra-intestinal effect, infusion access and patient priorities through specialist shared decision-making.
- Document induction regimen, treatment target, assessment date, maintenance plan and what symptoms require withholding treatment or contacting the IBD service.