Discontinuation of advanced therapy in inflammatory bowel disease: Updated evidence, guidelines, and personalized decision-making one year later

Abstract

Therapy discontinuation in inflammatory bowel disease, particularly involving immunomodulators, biologics, and small molecules, remains a controversial and evolving topic. This letter reflects on developments following the publication by Meštrović et al, emphasizing the complex balance between risks of relapse, anti-drug antibody formation, and potential complications of long-term immunosuppression. Recent evidence underscores high relapse rates following withdrawal - especially of anti-tumor necrosis factor agents - and highlights the lack of robust data for newer biologics. Updated guidelines from European Crohn’s and Colitis Organization, British Society of Gastroenterology, and American College of Gastroenterology all support cautious and individualized approaches, with strict criteria and close follow-up, particularly in Crohn’s disease. For ulcerative colitis, therapeutic cycling remains insufficiently addressed. We proposed a flowchart to support clinical decision-making and stress the importance of shared decision-making in the era of personalized medicine since, despite new drug classes and evolving strategies, the therapeutic ceiling in inflammatory bowel disease has yet to be fully overcome.

Keywords: Crohn’s disease; Ulcerative colitis; Inflammatory bowel disease; Biologic therapy; Discontinuation of therapy; Personalized medicine

Core Tip: Discontinuation of advanced therapies in inflammatory bowel diseases remains a high-stakes decision, with relapse, immunogenicity, and long-term complications all weighing heavily. Despite updated international guidelines and emerging therapies, a personalized, closely monitored approach remains essential to ensure safe and effective treatment de-escalation in both Crohn’s disease and ulcerative colitis.