Second United Arab Emirates consensus guidance on the diagnosis and management of inflammatory bowel disease

Table 1 Summary of the United Arab Emirates inflammatory bowel disease consensus guidance statements

No.	Consensus statement	Evidence; strength; consensus (%)
Diagnosis and classification of IBD
1	No single reference standard exists for diagnosing CD or UC; diagnosis requires integration of clinical history, biochemical markers, stool studies, endoscopy, histology, and imaging	5; strong; 100
2	Early detection of IBD is crucial to preventing complications and improving outcomes. Validated screening tools, such as the red flags index and IBD-REFER, may aid in triaging patients or referrals based on clinical history	3b; strong; 100
3	The differentiation between CD and UC should be based on a combination of clinical, endoscopic, histologic, and radiologic findings, as no single modality is diagnostic	3b; strong; 100
4	Diagnostic evaluation must exclude other potential causes of colitis, including infections (Clostridioides difficile, Salmonella, Shigella, Campylobacter, Cytomegalovirus, Mycobacterium tuberculosis, and Yersinia enterocolitis), ischemic colitis, drug-induced enteritis, and neoplasia	3b; strong; 100
5	Extraintestinal manifestations and presence of perianal disease of IBD should be assessed at the time of diagnosis and during the course of the disease, as they may precede or accompany gastrointestinal symptoms	3b; strong; 100
6	Fecal calprotectin should be used as non-invasive screening tools for differentiating IBD from functional bowel disorders, with values > 250 μg/g strongly suggestive of active inflammation	3b; strong; 100
7	Serum CRP should be measured at baseline for all suspected IBD cases, but their utility is limited by lack of specificity	3b; strong; 100
8	Iron deficiency anaemia, hypoalbuminemia, and vitamin deficiencies may provide indirect evidence of chronic inflammation and should be assessed at diagnosis	3b; strong; 100
9	Genetic and serological testing in isolation is not recommended for routine IBD diagnosis due to low predictive value and lack of clear clinical utility	3b; strong; 100
10	Ileocolonoscopy with segmental biopsies is required for the initial diagnosis of suspected IBD, except in acute severe colitis, where sigmoidoscopy with biopsy is preferred	2a; strong; 100
11	Endoscopic differentiation of CD and UC should be based on characteristic features: UC typically presents with continuous inflammation, loss of vascular pattern, and superficial ulceration, whereas CD is often characterized by skip lesions, cobblestoning, deep ulcerations, strictures, and fistulas	3b; strong; 91
12	At the time of index ileocolonoscopy, if endoscopic evidence of active inflammation, two to four biopsies should be obtained from at least five segments (rectum, sigmoid, descending, transverse, and ascending colon) and the terminal ileum, including areas of both inflamed and non-inflamed mucosa	5; strong; 100
13	Upper gastrointestinal endoscopy should be performed in patients with suspected upper gastrointestinal involvement	4; strong; 100
14	Capsule endoscopy may be considered for patients with suspected small bowel CD when ileocolonoscopy and cross-sectional imaging are inconclusive with prior assessments	3b; strong; 100
15	Histologic confirmation of IBD is essential and should include evaluation for crypt architectural distortion, basal plasmacytosis, granulomas, and transmural inflammation	3b; strong; 100
16	Cross-sectional imaging (MRI, MRE, CT, CTE, or intestinal ultrasound) should be performed in all patients with suspected small bowel CD to assess disease extent, stricturing, and complications	2a; strong; 100
17	MRE is the preferred imaging modality for small bowel assessment due to its superior soft-tissue contrast and lack of radiation exposure	2a; strong; 100
18	CTE may be used when MRE is unavailable, contraindicated, or in acute settings requiring rapid evaluation	2a; strong; 100
19	Pelvic MRI should be performed in patients with suspected perianal CD to evaluate fistulae and abscesses	2a; strong; 91
20	Intestinal ultrasound is an emerging modality that may serve as a point-of-care tool for assessing disease activity but has limited use as sole radiological investigation for diagnosis	3b; conditional; 100
21	The Montreal classification should be used for CD and UC in adults to enable standardization of disease characterization, aid in prognostication, and guide treatment decisions	3b; strong; 100
Assessment of disease activity (UC)
22	The Simple Clinical Colitis Activity Index should be used for routine clinical assessment of UC due to its validity, reliability, and inclusion of urgency and nocturnal bowel movements. The partial Mayo score may be used but clinicians need to be aware of its subjectivity	3b; strong; 82
23	The Truelove and Witts’ criteria should be used to identify acute severe UC requiring hospitalization and intravenous corticosteroids	3b; strong; 82
24	Fecal calprotectin should be used as a non-invasive screening tool for differentiating inflammatory disorders such as IBD from functional bowel disorders, with values > 250 μg/g strongly suggestive of active inflammation	3b; strong; 100
25	The Ulcerative Colitis Endoscopic Index of Severity or Mayo endoscopic subscore should be used to endoscopic scoring of disease activity	3b; strong; 100
26	Histological assessment should complement endoscopic assessment	3b; strong; 100
27	Intestinal ultrasound should be considered where available for non-invasive disease monitoring	3b; conditional; 100
Assessment of disease activity (CD)
28	A patient-reported outcome measure such as HBI or patient-reported outcome 2 is recommended for routine clinical assessment of CD. The Perianal Crohn’s Disease Activity Index should be considered to assess perianal disease activity	3b; strong; 100
29	Fecal calprotectin may be considered to monitor disease activity and response to treatment in CD, with greater sensitivity for colonic involvement than ileal disease. Changes in fecal calprotectin over time should guide disease monitoring	3b; strong; 100
30	The Simple Endoscopic Score for CD should be the preferred tool for routine endoscopic assessment in CD. The Rutgeerts score should be used in CD to assess the risk of recurrence at the anastomosis site following ileocolic resection	3b; strong; 100
31	Histological assessment should complement endoscopic assessment	4; strong; 100
32	Radiological assessment should be integrated into disease monitoring of CD, with the Magnetic Resonance Index of Activity as the preferred objective tool for evaluating luminal disease activity. Intestinal ultrasound may be used where available for non-invasive monitoring	3b; strong; 100
Markers of disease severity in IBD
33	In UC, certain risk factors including younger age at diagnosis (< 40 years), extensive colitis (E3), steroid dependency, severe endoscopic disease activity, presence of extraintestinal manifestations including primary sclerosing cholangitis a more aggressive disease course and higher colectomy risk, warranting consideration of early therapeutic escalation	3b; strong; 100
34	In CD, certain risk factors including young age at onset (< 40 years), perianal involvement, deep ulcers on endoscopy, active smoking and extensive small bowel disease predict a more severe disease course, justifying early advanced therapy	3b; strong; 91
35	Smoking significantly worsens CD outcomes, contributing to treatment resistance, complications, and post-surgical recurrence, making smoking cessation a key management priority	2b; strong; 100
Early disease control in IBD
36	Early initiation of advanced therapy should be prioritized in moderate-to-severe CD or high-risk phenotypes to prevent disease progression, complications, and irreversible bowel damage	1a; strong; 100
37	In UC, the benefits of early advanced therapy remain uncertain, but combination infliximab and azathioprine may be considered as an option in steroid-responsive acute severe UC for superior outcomes	1b; strong; 91
38	Mild CD, defined by the absence of complications, systemic symptoms, and significant endoscopic or biomarker evidence of inflammation, may be managed initially with conventional therapies such as dietary modification, oral budesonide and smoking cessation. However, close monitoring is essential, and advanced therapies should be considered early in patients with risk factors for disease progression	5; strong; 91
Treat to target strategy in IBD
39	The treat-to-target strategy should be the standard approach in IBD management, integrating objective disease monitoring to optimize treatment, guide therapy escalation when targets are unmet, and prevent complications	1b; strong; 91
40	Short-term targets should include symptomatic response within twelve weeks of therapy initiation, recognizing that symptom relief alone does not confirm inflammation control	1b; strong; 100
41	Biochemical remission, defined by normalization of inflammatory biomarkers (for example CRP < 5 mg/L, fecal calprotectin < 250 μg/g), should be the medium-term treatment target (3 months to 6 months of initiation), guiding therapy escalation when unmet	1b; strong; 91
42	Endoscopic remission, defined as absence of ulcers in CD and a Mayo endoscopic score of 0-1 in UC, should be the primary long-term treatment target (6 months to 12 months of initiation), with histologic and transmural healing as aspirational goals	2a; strong; 100
43	Quality of life and disability reduction should be considered as complementary long-term targets in IBD management	3b; strong; 100
Medical therapies (UC)
44	5-ASA should be the first-line therapy for induction and maintenance of remission in mild to moderate UC	1a; strong; 100
45	For patients with active moderate UC, a higher dose of oral mesalamine (4.8 g/day) should be considered, particularly in those with prior corticosteroid use or persistent symptoms. For maintenance of remission a lower dose may be considered once disease control is achieved	1a; strong; 100
46	Combination therapy with oral and topical mesalamine should be preferred for left-sided or extensive UC, while topical mesalamine alone may be used for ulcerative proctitis	1a; strong; 91
47	Oral prednisolone may be used for inducing remission in moderate to severe UC, with a tapering strategy based on clinical response. Budesonide MMX may be considered for induction of remission for mild to moderate UC	1a; strong; 100
48	For active distal UC, combination therapy with topical 5-ASA and topical/rectal steroids maybe considered for induction of remission	1a; strong; 100
49	Corticosteroids should not be used for the maintenance of remission in UC due to their unfavorable long-term safety profile and lack of efficacy in preventing relapse	1a; strong; 100
50	Thiopurine monotherapy is not recommended for induction of remission in UC due to its slow onset of action and lack of robust supporting evidence	1a; strong; 100
51	Thiopurines may be used in combination with infliximab for remission in moderate-to-severe UC	1b; strong; 100
52	Thiopurines may be used for long-term maintenance of remission in UC, but their use should be weighed against their safety profile relative to certain advanced therapies	2a; strong; 91
53	Methotrexate as monotherapy is not recommended for the induction or maintenance of remission in UC due to a lack of consistent efficacy in clinical trials	1b; strong; 100
54	Infliximab is recommended for the induction and maintenance of remission in moderate-to-severe UC based on robust evidence from randomized controlled trials	1b; strong; 100
55	Combination therapy with infliximab and azathioprine is superior to monotherapy for corticosteroid-free remission and mucosal healing in advanced therapy-naive patients with moderate-to-severe UC	1b; strong; 100
56	Subcutaneous infliximab (CT-P13 SC) is an effective maintenance therapy following intravenous induction in moderate-to-severe UC	1b; strong; 100
57	Switching from intravenous to subcutaneous infliximab (120 mg, every other week) is safe and effective in UC, but patients on intensified IV dosing (10 mg/kg, every 4 weeks) have a higher relapse risk. These patients may require upfront dose escalation (240 mg, every other week) to maintain remission	2a; strong; 91
58	Adalimumab may be considered for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
59	Golimumab is recommended for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 82
60	Vedolizumab is recommended for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
61	Ustekinumab is recommended for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
62	Risankizumab is recommended for the induction and maintenance of remission in moderate-to-severe UC with both 180 mg and 360 mg every 8 weeks as effective maintenance dosing options	1b; strong; 100
63	Mirikizumab is recommended for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
64	Guselkumab is effective for the induction and maintenance of remission in moderate-to-severe UC, with both intravenous and subcutaneous induction strategies available	1b; strong; 100
65	For maintenance therapy, guselkumab should be administered subcutaneously, with both 200 mg every 4 weeks and 100 mg every 8 weeks as effective dosing options	1b; strong; 100
66	Tofacitinib is effective for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
67	Upadacitinib is effective for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
68	Ozanimod is effective for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
69	Etrasimod is effective for the induction and maintenance of remission in moderate-to-severe UC	1b; strong; 100
70	Etrasimod may be considered as a treatment option for patients with moderate-to-severe isolated proctitis who require advanced therapy	1b; conditional; 100
Medical therapies (CD)
71	Oral 5-ASA are not recommended for the induction or maintenance of remission in CD due to a lack of significant benefit over placebo	1a; strong; 100
72	Sulfasalazine (not mesalazine) may provide modest benefit for induction of remission in mild Crohn’s colitis	1a; weak; 91
73	Systemic corticosteroids are effective for inducing remission in active CD but should not be used for long-term maintenance due to safety concerns and lack of sustained efficacy	1a; strong; 100
74	Budesonide 9 mg once daily is an effective induction therapy for mild to moderate ileal and right colonic CD, offering a better safety profile than systemic corticosteroids	1b; strong; 100
75	Thiopurine monotherapy is not recommended for the induction of remission in CD due to limited efficacy	1a; strong; 100
76	Thiopurines may be considered for maintenance of remission in CD, particularly in corticosteroid-dependent patients, but their effectiveness is lower compared to advanced therapies	1a; weak; 91
77	Combination therapy with infliximab and azathioprine is more effective than either agent alone for achieving clinical remission and mucosal healing in CD	1b; strong; 100
78	Intramuscular methotrexate may be considered for inducing and maintaining remission in CD; however, its use should be weighed against its safety profile relative to certain advanced therapies	1a; strong; 100
79	Methotrexate may be used in combination with anti-TNF therapy to reduce immunogenicity in patient’s intolerant or unsuitable for thiopurines	1b; weak; 100
80	Infliximab is recommended for the induction and maintenance of remission in moderate-to-severe CD	1b; strong; 100
81	Combination therapy with infliximab and azathioprine is superior to monotherapy for corticosteroid-free remission and mucosal healing in biologic-naive CD	1b; strong; 100
82	Infliximab is recommended for achieving and sustaining fistula closure in perianal and rectovaginal fistulizing CD	1b; strong; 100
83	Subcutaneous infliximab (CT-P13 SC) is an effective maintenance therapy following intravenous induction in moderate-to-severe CD	1b; strong; 100
84	Switching from intravenous to subcutaneous infliximab (120 mg, every other week) is safe and effective in CD, but patients on intensified IV dosing (10 mg/kg, every 4 weeks) have a higher relapse risk. These patients may require upfront dose escalation (240 mg, every other week) to maintain remission	2b; strong; 91
85	Adalimumab is recommended for the induction and maintenance of remission in moderate-to-severe CD	1b; strong; 91
86	Certolizumab is recommended for the induction and maintenance of remission in moderate-to-severe CD	1b; strong; 91
87	Vedolizumab is recommended for the induction and maintenance of remission in moderate-to-severe CD. Patients who do not achieve response at week 6 may benefit from an additional intravenous dose at week 10. The clinical decision support tool may be used to guide patient selection for its use in CD	1b; strong; 91
88	Ustekinumab is recommended for the induction and maintenance of remission in moderate-to-severe CD	1b; strong; 100
89	Risankizumab is recommended for the induction and maintenance of remission in moderate-to-severe CD colitis with both 180 mg and 360 mg every 8 weeks as effective maintenance dosing options	1b; strong; 100
90	Mirikizumab is recommended for the induction and maintenance of remission in moderate-to-severe CD	1b; strong; 100
91	Guselkumab is effective for the induction and maintenance of remission in moderate-to-severe CD, with both intravenous and subcutaneous induction strategies available	1b; strong; 100
92	For maintenance therapy in CD, guselkumab should be administered subcutaneously, with both 200 mg every 4 weeks and 100 mg every 8 weeks as effective dosing options	1b; strong; 100
93	Upadacitinib is recommended for the induction and maintenance of remission in moderate-to-severe CD	1b; strong; 100
Safety and monitoring of therapies in IBD
94	A comprehensive pre-advanced therapy safety screening (that includes hepatitis B, hepatitis C, and tuberculosis) should be performed before initiating advanced therapy to minimize the risk of opportunistic infections and complications associated with immunosuppression. HIV testing should be considered in vulnerable individuals as defined by World Health Organization	3b; strong; 100
95	Patients with latent tuberculosis should receive full chemoprophylaxis before initiating biologic or small-molecule therapy, following treatment protocols and durations as per institutional antimicrobial policies and appropriate referral to infectious disease specialists. Biologic or small-molecule therapy should be delayed for at least 4 weeks after initiating tuberculosis treatment, unless clinically urgent, in which case specialist advice is required	3b; strong; 100
96	Patients with chronic hepatitis B (positive hepatitis B surface antigen) should receive antiviral prophylaxis, preferably with tenofovir or entecavir, initiated at least two weeks before therapy and continued for at least 12 months after cessation, while those with resolved infection should undergo regular monitoring for reactivation	3b; strong; 91
97	Patients with IBD and hepatitis C should be treated with direct-acting antiviral agents according to national and international guidelines, with close monitoring during antiviral therapy due to limited data on its impact in immunosuppressed patients	2a; strong; 100
98	Regular renal and hepatic function monitoring is essential during mesalamine therapy to detect potential adverse effects, including interstitial nephritis and hepatotoxicity, with baseline serum creatinine assessment and periodic renal and liver function tests recommended	3b; strong; 100
99	Corticosteroid use in IBD should be limited to short induction courses with rapid tapering, and prolonged or repeated use should be avoided due to risks including osteoporosis, infections, adrenal insufficiency, and increased mortality	3b; strong; 100
100	Patients requiring corticosteroid therapy should receive calcium and vitamin D supplementation, and those at risk of adrenal insufficiency after prolonged use should undergo adrenal function assessment before withdrawal with appropriate referral to endocrinology services	3b; strong; 82
101	Thiopurines require regular monitoring due to risks of opportunistic infections, hepatotoxicity, bone marrow suppression, and malignancy, including an increased risk of lymphoma and nonmelanoma skin cancer; thiopurine methyltransferase and nudix hydrolase 15 genotyping may be considered before initiation to guide dosing	2a; strong; 91
102	Methotrexate requires routine monitoring for hepatotoxicity, bone marrow suppression, and pulmonary toxicity, with folic acid supplementation recommended to mitigate hematologic toxicity; it is contraindicated in pregnancy and should be discontinued at least three months before conception	3b; strong; 100
103	Anti-TNF agents require thorough safety monitoring due to risks of serious infections, malignancy, immunogenicity, and metabolic effects	2a; strong; 100
104	Anti-TNFs should be avoided in patients with New York Heart Association class III/IV heart failure, active malignancy, or demyelinating disorders, with treatment initiation delayed for at least two years in low-risk malignancies and five years in high-risk cases	3b; strong; 91
105	Vedolizumab has a favorable safety profile with no significant increased risk of infections, malignancies, or hepatic toxicity; however, routine monitoring of liver function is recommended due to rare hepatobiliary events	2a; strong; 100
106	Vedolizumab may be a preferred advanced therapy in patients with a history of malignancy due to its gut-selective mechanism and lack of observed increased cancer recurrence risk	3b; strong; 91
107	IL-12/IL-23 and IL-23 inhibitors have a favorable safety profile in IBD; however, herpes zoster infections and transient liver enzyme elevations may occur, necessitating routine liver function monitoring	2a; strong; 91
108	JAK inhibitors require close monitoring due to potential risks of infections, malignancy, cardiovascular events, thromboembolism, and metabolic disturbances, with recommended screening for CBC, liver function, herpes zoster, lipid levels, and liver function before and during treatment	2a; strong; 100
109	JAK inhibitors are contraindicated in pregnancy due to teratogenicity and should be discontinued before conception, with effective contraception advised during treatment	3b; strong; 100
110	S1PR modulators require monitoring for lymphopenia, liver enzyme elevations, hypertension, and cardiac conduction abnormalities, with baseline and periodic assessments of CBC, liver function, blood pressure, ophthalmic examination and electrocardiogram in at-risk patients	2a; strong; 100
111	S1PR modulators are contraindicated in patients with significant cardiac conduction disorders, pre-existing cardiovascular disease, decompensated heart failure, recent stroke, or uncontrolled hypertension, and should not be used in patients taking monoamine oxidase inhibitors	3b; strong; 100
112	S1PR modulators are contraindicated in pregnancy due to teratogenicity and should be discontinued before conception, with effective contraception advised during treatment	3b; strong; 100
Positioning and sequencing of advanced therapies
113	Advanced treatment selection for UC and CD should be individualized, integrating disease characteristic and severity, prior treatment history, safety considerations and patient-specific factors rather than relying on rigid sequencing algorithms	5; strong; 100
114	Advanced therapy selection should incorporate evidence-informed comparative efficacy, particularly in biologic-exposed patients where some therapies may be less effective	2a; strong; 100
115	Infliximab remains the preferred first-line biologic for perianal fistulizing CD, with combination therapy (infliximab plus an immunomodulator) improving fistula closure rates	1; strong; 100
116	In select cases such as limited ileocecal disease or advanced complicated disease, surgery may be considered as a first-line option instead of prolonged or ineffective medical therapy	1b; conditional; 100
Response assessment and optimization of advanced therapies
117	Response to induction therapy should be assessed between weeks 10 and weeks 14, guided primarily by clinical and biomarker response, with endoscopic evaluation reserved for selected cases	5; strong; 100
118	Patients should ideally achieve clinical remission before transitioning to maintenance therapy, though in practice, a significant clinical response is an acceptable goal to proceed with maintenance	5; strong; 100
119	Extended induction may be considered with certain advanced therapies for patients who exhibit an inadequate response following the standard induction phase	2a; conditional; 91
120	LOR is defined as the recurrence of clinical symptoms or objective markers of active disease after an initial response to therapy. In suspected LOR, non-inflammatory conditions such as IBS, bile acid malabsorption, small intestinal bacterial overgrowth, structural complications, and infections should be ruled out before adjusting treatment	5; strong; 100
121	In confirmed LOR, if pharmacokinetic failure is suspected, ideally guided by TDM, therapy should be intensified or switched within class, particularly for anti-TNF agents. If mechanistic failure is suspected, switching to a therapy with a different mechanism of action should be prioritized	2a; conditional; 100
122	Dual advanced therapy may be considered in highly refractory cases, particularly for perianal CD with close safety monitoring and informed consent	3b; conditional; 100
123	Difficult-to-treat IBD should be defined by failure of at least two advanced therapies with different mechanisms of action, recurrent CD following two or more resections, chronic antibiotic-refractory pouchitis, complex perianal CD, or significant psychosocial comorbidities that interfere with management	5; strong; 100
124	Patients meeting criteria for difficult-to-treat IBD should be referred to a specialized IBD center with access to multidisciplinary care and clinical trials. Early referral ensures timely optimization of complex treatment strategies and access to therapies beyond standard practice	5; strong; 100
125	Proactive TDM at week 14 post-induction and during maintenance is recommended with infliximab to optimize drug exposure, reduce immunogenicity, and improve long-term outcomes. Reactive TDM should be used to guide dose adjustments in cases of primary nonresponse or secondary loss of response	1b; strong; 100
126	Dose intensification with infliximab, either through interval shortening or higher dosing, is effective for secondary loss of response due to low drug levels in absence of anti-drug antibodies and should be guided by TDM	2a; conditional; 100
127	In acute severe UC, accelerated induction or higher initial doses of infliximab may be considered in steroid-refractory cases, but randomized data do not support routine escalation to 10 mg/kg induction. Patient selection should be guided by clinical and biomarker indicators	1b; conditional; 82
128	TDM for adalimumab is recommended, as higher drug levels correlate with improved long-term outcomes. Proactive TDM, post-induction, may optimize drug exposure and reduce early loss of response	2a; strong; 82
129	Dose intensification with adalimumab to 40 mg weekly may be considered for loss of response, guided by reactive TDM. Higher induction dosing has not demonstrated superior efficacy, but maintenance dose adjustments based on pharmacokinetics and inflammatory burden may improve outcomes	1b; conditional; 100
130	The role of TDM in golimumab remains unclear, though higher drug levels correlate with improved outcomes. While early proactive monitoring may help optimize response, routine TDM is not currently recommended	3b; conditional; 82
131	Dose intensification with golimumab to 100 mg every 4 weeks may be considered for UC patients with inadequate response, as it can recapture response in select cases. Proactive optimization strategies incorporating TDM may further enhance outcomes	2a; conditional; 82
132	TDM for certolizumab pegol in CD remains exploratory, with emerging evidence suggesting higher drug levels correlate with improved outcomes. However, no definitive therapeutic thresholds have been established, and its routine use is not recommended	3b; conditional; 91
133	Dose intensification with certolizumab may be considered for refractory CD, but available data show mixed results, and non-TDM-based escalation does not consistently improve outcomes	3b; conditional; 91
134	TDM for vedolizumab is not routinely recommended, though higher drug levels correlate with improved outcomes. Immunogenicity is low, and combination therapy with immunomodulators does not significantly impact drug levels	3b; conditional; 100
135	An additional week 10 dose may be considered for delayed responders to vedolizumab in CD, though its benefit in UC remains uncertain. Dose intensification of vedolizumab to every 4 weeks can restore response in some secondary non-responders but is not effective for primary non-response	1b; conditional; 100
136	TDM for ustekinumab is not routinely recommended, as no clear exposure-efficacy targets exist, and immunogenicity is low and combination therapy with immunomodulators does not significantly impact drug levels	3b; conditional; 100
137	Dose intensification with ustekinumab, including interval shortening or IV reinduction, may be considered for patients with secondary loss of response in CD, as observational data suggest clinical benefit in select cases. However, randomized trials have not consistently demonstrated superiority of IV reinduction followed by every 4 weeks maintenance over standard dosing	2a; conditional; 100
138	TDM for risankizumab is not recommended in view of very low anti-drug antibody rates and the absence of defined exposure-efficacy targets	3b; strong; 100
139	Extended induction with risankizumab with a further three IV induction doses may be considered for non-responders at week 12 in CD and UC. In CD, a single IV rescue dose of 1200 mg or dose intensification to 4 weekly subcutaneous maintenance injections may be considered for secondary loss of response. There is currently insufficient evidence to recommend dose intensification for UC	2a; conditional; 82
140	Routine therapeutic drug monitoring for mirikizumab is not recommended due to its low immunogenicity and minimal impact of anti-drug antibodies on efficacy. Fixed dosing is appropriate based on current evidence	3b; strong; 100
141	Extended induction with mirikizumab may be considered for UC patients with a delayed response, as an additional 12 weeks of induction has shown benefit. However, there is currently insufficient evidence to recommend dose intensification strategies for mirikizumab in UC or CD	2a; conditional; 100
142	TDM for guselkumab is not currently recommended due to the low incidence of anti-drug antibodies and neutralizing antibodies, with no significant impact on drug levels, efficacy, or safety	3b; strong; 100
143	There is currently insufficient evidence to recommend extended induction with guselkumab for post-induction primary non-response or inadequate response. The role of dose intensification following loss of response with guselkumab remains undefined, but based on clinical trial data, escalation to 200 mg every 4 weeks may be considered in patients on 100 mg every 8 weeks on an individual basis in CD	2a; conditional; 91
144	TDM is not recommended for JAK inhibitors, including tofacitinib and upadacitinib, due to their predictable pharmacokinetics, dose-proportional exposure, and lack of immunogenicity	3b; strong; 100
145	Extended induction with tofacitinib (10 mg twice a day for up to 16 weeks) may be considered in UC patients who do not respond after 8 weeks; however, it should be used selectively due to a lack of long-term safety data. Dose escalation from 5 mg twice a day to 10 mg twice a day can recapture response in some patients but must be weighed against potential risks, including venous thromboembolism and herpes zoster	2a; conditional; 91
146	Extended induction with upadacitinib (16 weeks in UC, 24 weeks in CD) may be considered for delayed responders, while dose escalation to 30 mg once daily can recapture response in select patients. However, safety concerns, including risks of venous thromboembolism, herpes zoster, and malignancy, should be carefully considered before dose intensification	2a; conditional; 91
147	Therapeutic drug monitoring is not recommended for S1PR modulators due to predictable pharmacokinetics and lack of immunogenicity. There is insufficient evidence to recommend extended induction or dose optimization strategies for managing loss of response	3b; conditional; 100
Withdrawal of therapy in IBD
148	Stopping infliximab may significantly increase relapse risk in CD and UC. Discontinuation should only be considered in carefully selected patients with sustained deep remission, with close monitoring for early signs of disease recurrence	1a; conditional; 100
149	Thiopurine withdrawal may be considered in patients with CD in sustained steroid-free clinical remission on combination therapy with infliximab for at least 6 months, particularly in those with stable infliximab trough levels and low immunogenicity risk. Post-withdrawal monitoring with biomarkers and scheduled TDM is essential to detect early relapse	1b; conditional; 100
150	There is currently insufficient evidence to recommend the routine discontinuation of non-anti-TNF biologics or small molecules in patients in remission. The limited data available suggest a significant risk of relapse upon withdrawal. Therefore, any decision to stop therapy must be individualized, balancing the risks of long-term drug exposure against the consequences of a disease flare, and made with caution	4; conditional; 100
Management of ASUC
151	Intravenous corticosteroids remain the cornerstone of initial therapy for ASUC, with early response assessment using Travis criteria at day 3 to identify patients requiring rescue therapy	1b; strong; 100
152	Rescue therapy with infliximab or cyclosporine is recommended for steroid-refractory ASUC, with the choice guided by prior therapy exposure, clinician expertise, and potential toxicity concerns. Sequential rescue therapy (e.g., cyclosporine or JAK inhibitors after infliximab failure) should generally be avoided due to high complication risks	1b; strong; 91
153	Early involvement of a colorectal surgeon is essential for patients with ASUC, with colectomy recommended for those failing to respond within 7 days of rescue therapy, developing complications (e.g., toxic megacolon, perforation), or being unsuitable for medical therapy	2a; strong; 100
154	JAK inhibitors may be considered as rescue therapy for steroid-refractory ASUC in selected patients, though their role as first-line rescue therapy remains under investigation	1b; conditional; 100
Management of stricturing CD
155	Medical therapy remains the first-line approach for inflammatory CD-associated strictures, with anti-TNF agents such as infliximab, particularly in combination with thiopurines, demonstrating the strongest evidence for treatment success	1b; strong; 100
156	Endoscopic balloon dilation should be considered for fibrotic strictures < 5 cm without deep ulceration or penetrating complications, with repeat dilations required in over half of cases within 12 months	2a; strong; 91
157	Surgical intervention is indicated for strictures refractory to medical or endoscopic therapy, particularly in the presence of penetrating complications or significant pre-stenotic dilation, with the choice between resection and stricturoplasty guided by bowel preservation principles	2a; strong; 100
Management of perianal CD
158	Infliximab in combination with azathioprine is the preferred first-line biologic therapy for perianal fistulizing CD	1b; strong; 100
159	Before initiating biologic therapy, adequate perianal sepsis control through examination under anaesthesia, abscess drainage, and seton placement is recommended to reduce the risk of treatment failure and recurrent infections	3b; strong; 100
160	Combination therapy with infliximab and surgical interventions, including seton placement, is associated with superior outcomes in complex fistulizing CD compared to either modality alone	2a; strong; 100
161	Upadacitinib may be considered as a preferred second-line option over other agents for perianal fistulizing CD in patients with failure or intolerance to anti-TNF therapy	2b; weak; 100
Management of intra-abdominal abscesses in CD
162	Percutaneous drainage is generally preferred to surgical drainage for intra-abdominal abscesses in CD when feasible, as it may enable earlier biologic therapy and avoid immediate surgery. However, select patients may respond to antibiotics alone, particularly for smaller or less complex abscesses. Surgery should be considered if drainage is not feasible, unsuccessful, or if sepsis persists	2b; strong; 100
Post-operative prevention of recurrence of CD
163	Post-operative prophylactic therapy should be considered in high-risk patients for prevention of early disease recurrence (e.g., smokers, prior resections, penetrating or perianal disease, younger age, histologic risk factors) to prevent early disease recurrence, with anti-TNFs being the preferred first-line option and vedolizumab as an alternative in select cases	1b; strong; 91
164	Anti-interleukin therapies (anti-IL12/IL-23 and anti-IL23) and JAK may be considered on a case-by-case basis for post operative recurrence prevention	5; conditional; 100
165	Early post-operative endoscopic assessment (within 6-12 months) using the modified Rutgeerts score is recommended to guide therapy escalation, with i2b or higher lesions warranting immediate treatment intensification	1b; strong; 100
Management of IBD in pregnancy
166	Preconception counselling should be provided to all individuals with IBD planning pregnancy, emphasizing the importance of achieving sustained steroid-free remission for at least 3-6 months before conception to optimize maternal and fetal outcomes	3b; strong; 100
167	Referral to an obstetrician-gynecologist, ideally one with expertise in high-risk pregnancies, and multidisciplinary team co-management are recommended for individuals with IBD during pregnancy	5; strong; 100
168	Aminosalicylates, thiopurines, anti-TNFs, vedolizumab, ustekinumab and IL-23 inhibitors are considered safe and should generally be continued during pregnancy, as active disease poses greater risks than medication exposure. Methotrexate, JAK inhibitors, and S1PR modulators should be discontinued prior to conception due to teratogenicity	3b; strong; 91
169	Pregnant individuals with IBD should undergo routine disease monitoring using fecal calprotectin and CRP each trimester. Endoscopy should be reserved for strong clinical indications, while MRE (without gadolinium) and intestinal ultrasound are preferred for imaging when necessary	3b; strong; 100
170	Labor and delivery planning should be individualized, with vaginal delivery being safe for most patients. Caesarean section is recommended in cases of active perianal disease or prior ileal pouch-anal anastomosis surgery to reduce the risk of complications	3b; strong; 100
171	Breastfeeding should be encouraged in individuals with IBD, as most medications, including 5-ASA, thiopurines, anti-TNFs, vedolizumab, ustekinumab, and IL-23 inhibitors, have minimal transfer into breast milk and do not pose significant risks. Methotrexate, JAK inhibitors, and S1PR modulators should be avoided	3b; strong; 91
172	Infants exposed to biologics in utero, particularly anti-TNFs, should avoid live vaccines (e.g., bacillus Calmette-Guerin) for the first 12 months of life due to prolonged drug clearance. The 12-month recommendation is based on ECCO guidelines. The oral polio vaccine is contraindicated in this setting; however, the inactivated polio vaccine can be safely administered. Live rotavirus vaccine may be provided on schedule in infants exposed to anti-TNFs in utero. Routine childhood vaccinations with inactivated vaccines should follow the standard immunization schedule	3b; strong; 100
Health maintenance
173	Patients with extensive colitis should undergo surveillance colonoscopy starting eight years after diagnosis, with the frequency guided by individual risk factors. High-definition virtual or dye-spray chromoendoscopy is the preferred method for dysplasia detection, with dye-spray chromoendoscopy preferred in those at greater risk of high-grade dysplasia (pre-existing low-grade dysplasia or concurrent primary sclerosing cholangitis)	1a; strong; 100
174	For patients with IBD and PSC, annual colonoscopic surveillance should begin at the time of PSC diagnosis due to the significantly increased risk of colorectal cancer	3b; strong; 100
175	Endoscopic resection is the preferred approach for well-demarcated, resectable dysplastic lesions. Colectomy should be considered for flat high-grade dysplasia, multifocal low-grade dysplasia, or non-resectable lesions, particularly in patients with PSC due to the high risk of malignancy	3b; strong; 100
176	Patients with IBD should receive routine age-appropriate cancer screening. Cervical cancer screening should be performed at standard intervals, with annual screening recommended for women on immunosuppressive therapy. Annual dermatologic screening is advised for patients on immunomodulators, anti-TNF agents, or small molecules	3b; strong; 100
177	All patients with IBD should receive routine vaccinations, with particular attention to annual inactivated influenza vaccination, pneumococcal vaccination, hepatitis B screening and immunization, and non-live recombinant herpes zoster vaccination for immunosuppressed individuals	3b; strong; 100
178	Live vaccines should be avoided in immunosuppressed patients. If necessary, live vaccines should be administered at least four weeks before initiating immunosuppression or at least three months after discontinuation	3b; strong; 100
179	BMD screening using DEXA should be performed in postmenopausal women, men aged ≥ 65 years, and any patient with corticosteroid exposure exceeding three months	3b; strong; 100
180	All IBD patients, particularly those on corticosteroids, should receive calcium and vitamin D supplementation. Patients with osteoporosis or below-normal BMD should be referred to endocrinology for further management	3b; strong; 100
181	Annual screening for anxiety and depression using validated tools (e.g., Patient Health Questionnaire-9, Generalized Anxiety Disorder-7) should be integrated into routine IBD care. Patients with moderate-to-severe symptoms should be referred to mental health professionals	3b; strong; 82
182	All patients with CD should be strongly advised to quit smoking, with access to pharmacologic and behavioral smoking cessation support	1; strong; 100
183	Patients with IBD may be encouraged to follow a Mediterranean-style diet - rich in fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins, and low in ultra processed foods, added sugars, and salt - when appropriate and tolerated. Patients with structuring disease should modify food texture to improve tolerance	3b; strong; 100
184	Regular physical activity and structured stress-reduction strategies should be recommended as part of comprehensive IBD management to improve both mental and physical health outcomes	3b; conditional; 100
Pathways towards equitable access to IBD care in the United Arab Emirates
185	Biosimilars should be considered where available, given their comparable efficacy and safety to originator biologics, with lower associated costs facilitating broader access	1b; strong; 100
186	Patient assistance programs should be expanded and promoted to help financially constrained patients access biologic and small-molecule therapies, with standardized application processes to improve accessibility	5; strong; 100
187	Charitable organizations should be recognized as key partners in supporting patients with financial barriers to IBD treatment, with structured referral pathways for eligible individuals	5; strong; 100
188	Healthcare providers should receive training on navigating insurance policies and financial assistance programs to facilitate access to advanced therapies for eligible patients	5; strong; 100

IBD: Inflammatory bowel disease; CD: Crohn’s disease; UC: Ulcerative colitis; CRP: C-reactive protein; MRI: Magnetic resonance imaging; MRE: Magnetic resonance enterography; CT: Computed tomography; CTE: Computed tomography enterography; HBI: Harvey-Bradshaw Index; 5-ASA: 5-aminosalicylates; TNF: Tumor necrosis factor; IL: Interleukin; HIV: Human immunodeficiency virus; CBC: Complete blood count; JAK: Janus kinase; S1PR: Sphingosine-1-phosphate receptor; LOR: Loss of response; TDM: Therapeutic drug monitoring; ASUC: Acute severe ulcerative colitis; ECCO: European Crohn’s and Colitis Organisation; PSC: Primary sclerosing cholangitis; BMD: Bone mineral density; DEXA: Dual-energy X-ray absorptiometry.