David T. Rubin, MD is a professor of medicine at the University of Chicago, director of the Inflammatory Bowel Disease Center, and chair of the International Organization for the Study of IBD (IOIBD).

David Rubin, MD

Comprehensive disease control is a familiar phrase in 

 circles by now. Pairing standardized quality-of-life measures with symptom control and endoscopic healing brings the endpoint closer to what patients actually experience. What remains less familiar is the first step: asking patients what the disease is actually taking from them.

David T. Rubin, MD, argues the concept alone will not move outcomes without a method attached to it: specific screening questions, validated instruments, and a therapy choice tied to what the screen turns up. Without it, quality of life stays a talking point rather than a target.

Patients with IBD carry a significantly higher burden of anxiety and depression than the general population. In a 2026 Norwegian cohort, 37.4% of patients with Crohn's disease and 32.1% with 

 screened positive for anxiety, compared with 17.5% among matched controls.¹ Despite this gap, the American Gastroenterological Association's recommendation of annual depression and anxiety screening for every adult with IBD is inconsistently followed in practice.²

Rubin is professor of medicine at the University of Chicago, director of the Inflammatory Bowel Disease Center, and chair of the International Organization for the Study of IBD (IOIBD). He built comprehensive disease control around three sequential tiers of remission: symptomatic relief, biological control of inflammation, and functional remission covering joint, mental, and sexual health. "If you don't ask, you won't know," Rubin said.

Below, Rubin walks through the specific questions and validated tools he uses to surface functional limitations patients rarely volunteer. He also explains why referral infrastructure and visit time work against routine screening, and how comorbid joint or skin disease guides his choice of therapy.

Q&A: IBD screening tools and biologic selection by comorbidity

HCPLive: Can you describe what comprehensive disease control means in inflammatory bowel disease? 

 The topic is comprehensive disease control, sometimes called comprehensive disease management. It's the evolution of our attempt to provide improved quality of life for people living with Crohn's disease and ulcerative colitis.

It's based on the principle that ultimately, what we're trying to do for anybody suffering from anything, frankly, is improve their quality of life. As much as our many treatments for Crohn's and colitis have evolved and multiplied, they're focused on specific clinical trial endpoints centered on the bowel. But we recognize these conditions affect much more than the intestines. To take care of people properly, we need to think about the whole person.

The way I describe it is a more holistic approach to management. Thinking about the whole person means addressing coexisting extraintestinal manifestations, like joint pain or skin inflammation, but also going beyond that to what I've started calling atypical extraintestinal manifestations, or less traditional ones, like mental health disorders. People with inflammatory bowel disease have a higher prevalence of anxiety and depression than those without IBD. Sexual health is affected by bowel conditions, so is sleep quality. Ultimately, what we're trying to do is improve individuals' functioning and quality of life, what I usually describe as an unrestricted, high quality of life.

The way I break this down in my practice is by talking to my patients about three types of remission. This is a chronic inflammatory problem in which the immune system of their gut is trying to do its job when it's not really needed, meaning it's active when, as far as we can tell, there's no threat or infection, and it's chronic, meaning it's not shutting itself off.

So when we talk about remission, the first thing is turning off the inflammation so the patient feels perfect: no pain, no diarrhea, no bleeding, no urgency. Second, we want objective evidence that we're controlling the disease process. That means biological markers of inflammation are normalized, whether that's scopes, stool tests, or blood tests. In children, it's growth and development. Those markers show you've controlled the actual inflammation beyond symptoms. The reason you have to look at both is that 50% of people who feel well or feel better will still be inflamed, and if you're still inflamed despite feeling okay, you will relapse. There'll be progression of the disease to a complication, or there'll be a full relapse of clinical symptoms. So the way I say it to people is: I want you to feel perfect, but I want it to last forever, and that means we have to control the disease process.

The third type of remission I call functional remission. This is where we say no joint pain, no skin inflammation, no depression or anxiety, your sexual health is restored, and you're able to do everything else you want to do in life: have children, work, go to school, maintain your career, travel without worry. Functional remission is our ultimate goal, but you have to do them in order. You want the bowel symptoms to be better, you want to control the disease process, then you want to make sure you're addressing all these other problems.

So comprehensive disease control is a construct that looks at an endpoint that includes the usual clinical trial endpoints of patient-reported symptoms and disease control related to endoscopy or labs, but it adds a standardized version of quality of life. When you add IBD quality-of-life measures to symptoms and endoscopy or other biomarkers, that's what we're calling CDC.

When you raise the bar, you start to realize that even when you have people whose bowels are perfect, you're not improving their quality of life because you haven't addressed the other issues. It sounds obvious, but the reality is that until you start looking at it and combining it with these other measures, you're not going to get a full picture of what it takes to heal. Healing is different than just treating inflammation.

HCPLive: How are you individualizing treatment options, and are certain patients at higher risk or likely to need more time?

 Those are great questions, and really important ones. The answer is, first, that if you don't ask, you won't know, and it starts by making sure you're not losing sight of your ultimate goal: an improved quality of life. Sometimes both the patient and the clinician can become too focused on bowel symptoms, or bleeding, or anemia. The reality is you end up missing the main picture: the patient may be unable to leave the house, or their hands hurt so they can't type, which is part of their job. There are other pieces to this, so you have to start by knowing you need to ask.

There are different ways to do that. One question you can ask a patient is, "What does having this disease prevent you from doing that you would want to do?" Or, "What are you unable to eat that you would like to enjoy?" You start to learn about somebody's limitations from the disease so you can develop a treatment plan that addresses them.

The other part is incorporating standardized and validated screening tools. If you want to know if somebody is anxious or depressed, there are measures you can use in clinic: a generalized anxiety scoring system, or the health questionnaire called the PHQ-9, which detects depression. If you screen for it, you will find it, and I'd challenge my colleagues to consider doing this, not only because it's in the guidelines for management, but because they'll uncover that many of their patients screen positive even when they had no idea. I've had colleagues say, "I can tell when one of my patients is depressed." I'd challenge that. I think there are a lot of people who are depressed that you'd never be able to tell in a limited clinical encounter.

But the other reason people don't routinely ask is you also have to have a treatment option and the ability to provide care if you identify these issues. Where are you going to refer the patient if they have depression or anxiety? Very few centers like ours have a psychogastroenterologist to refer them to, so we need a system in our clinics if we're going to screen for it, so that we're able to refer people. Or asking about sexual health: we're not taught that in medical school, or we weren't when I was in training. So how do you ask about that?

Meanwhile, who has time? I don't mean that as though it's not important, so why make time? I mean in a busy clinical practice, when you have a 20-minute encounter if you're lucky, most people only get 15, and you're trying to figure out how to talk about a new therapy, the goals of management, when their scope is due, any pre-testing before a new treatment, what their insurance may or may not cover, how you'll follow up on lab results. How do you do all that, and by the way, tell me about your sex life, or fill out this survey and tell me if you're anxious or depressed?

There are some very big system issues preventing us from providing the care people need. Whether we measure it in clinical trials or in post-hoc analyses and call it CDC, the real issue isn't just that we're underestimating the prevalence of these other problems. The issue is we need a different care model to give clinicians the time and resources to manage these conditions properly.

Now, the last part of this is choosing therapies, and this factors into quality of life and a variety of other things. If a patient has inflammatory joint problems coexisting with their IBD, you'd want to choose a treatment likely to cover the joint inflammation too, which means leaning toward an anti-TNF or a JAK inhibitor. If they have coexisting skin problems, whether psoriasis, erythema nodosum, or pyoderma, you might lean toward an IL-23 inhibitor, which is effective for skin and bowel together. You can pick therapies based on knowing about some of these other challenges. A patient with IBD deserves care that tries to address these issues. The reason it's not routinely done, and the reason it's important for HCPLive to discuss and share, is it hasn't been incorporated into practice the way it should be.

Editor’s Note: Rubin reports relevant disclosures with AbbVie, Takeda, Pfizer, Janssen, Bristol Myers Squibb, and others.

Johansen I, Hagen MC, Løkkeberg ST, et al. Anxiety and depression in newly diagnosed patients with inflammatory bowel disease (the IBSEN III study) compared with the general population in Norway. 

. 2026;20(3):jjag021. doi:10.1093/ecco-jcc/jjag021

Caldera F, Kane S, Hashash JG, et al. AGA Clinical Practice Update on Noncolorectal Cancer Screening and Vaccinations in Patients With Inflammatory Bowel Disease: Expert Review. 

. 2025;23(5). doi:10.1016/j.cgh.2024.12.011

Articles

Comprehensive disease control in IBD extends beyond bowel-centric endpoints by integrating symptom remission, objective inflammatory control, and functional remission encompassing mental, sexual, sleep, and extraintestinal health. Anxiety and depression are substantially more prevalent in Crohn’s disease and ulcerative colitis than in matched controls, yet guideline-recommended annual screening remains inconsistently implemented. Practical execution requires asking targeted limitation-focused questions and applying validated tools (e.g., GAD scales, PHQ-9), coupled to clear treatment and referral pathways. Time constraints and limited behavioral-health infrastructure remain major barriers.

David T. Rubin, MD, on the screening tools, direct questions, and therapy choices behind IBD's three tiers of remission.

Comprehensive Disease Control Starts With Asking, With David T. Rubin, MD

Improving quality of life for patients with inflammatory bowel disease (IBD) starts with a simple but often-skipped step: asking the right questions.

"If you don't ask, you won't know," David T. Rubin, MD,  professor of medicine at the University of Chicago and director of the Inflammatory Bowel Disease Center said in an interview with HCPLive.

Individualizing IBD Care Beyond the Bowel, With David T. Rubin, MD

According to Rubin, clinicians can become so focused on bowel symptoms, bleeding, or anemia that they miss the bigger picture affecting a patient's daily life.

Screening Questions to Identify IBD's Impact on Quality of Life

Rubin suggested 2 direct questions clinicians can use to uncover functional limitations that might otherwise go unspoken: "What does having this disease prevent you from doing that you would want to do?" and "What are you unable to eat that you would like to enjoy?"

"You start to learn more about somebody's limitations from the disease that you can develop a treatment plan that will address them," Rubin said.

Using Validated Screening Tools for Anxiety and Depression in IBD

Beyond open-ended questions, Rubin pointed to validated screening tools, such as a generalized anxiety scoring system and the Patient Health Questionnaire-9 (PHQ-9), as a way to catch what clinical impression alone often misses.

"If you screen for it, you will find it," Rubin said. He pushed back on the idea that experienced clinicians can simply tell when a patient is struggling. "I think that there's a lot of people who are depressed that you would never be able to tell in a limited clinical encounter."

Barriers to Comprehensive IBD Care in Clinical Practice

Rubin was candid about why these conversations don't happen more often, even when clinicians know they should. Referral infrastructure is thin. "Very few centers like ours have a GI psychologist or psychogastroenterologist... that I can refer them to," he said, adding that most clinicians were never trained to ask about sexual health in the first place.

Time is the other constraint. In a 15- to 20-minute visit already covering new therapies, upcoming scopes, insurance coverage, and lab follow-up, Rubin said, there's rarely room left for "tell me about your sex life, or fill out this survey and tell me if you're anxious or depressed."

"There's some very big system issues that are preventing us from providing the care that people need," Rubin said, arguing that the field needs a different care model, not just better awareness, to give clinicians the time and resources to manage these issues properly.

Selecting IBD Therapy Based on Extraintestinal Manifestations

Rubin said knowing about a patient's coexisting conditions can directly shape treatment selection. Patients with inflammatory joint problems alongside their IBD may be better served by an anti-tumor necrosis factor (TNF) therapy or a Janus kinase (JAK) inhibitor, both of which can address joint inflammation as well as bowel disease. Patients with coexisting skin conditions, such as psoriasis, erythema nodosum, or pyoderma, may benefit more from an interleukin-23 (IL-23) inhibitor, which Rubin said is effective for both skin and bowel.

"You can pick therapies based on knowing about some of these other challenges and problems," Rubin said. "The patient with IBD deserves care that tries to address these issues."

Hinnant L, Rios Villacorta N, Chen E, et al. Consensus statement on managing anxiety and depression in individuals with inflammatory bowel disease. 

Holmer AK, Chang S, Malter L. Selecting therapies in moderate to severe inflammatory bowel disease: key factors in decision making. 

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David T. Rubin, MD, on the questions, screening tools, and system barriers standing between IBD care and the whole patient.

has been measured almost exclusively by what's happening in the bowel. David T. Rubin, MD, a professor of medicine at the University of Chicago, director of the Inflammatory Bowel Disease Center, and chair of the International Organization for the Study of IBD (IOIBD), argues that definition is too narrow to capture what patients actually need.

"What we're trying to do for anybody who's suffering from anything, frankly, is improve their quality of life," Rubin said in an interview with HCPLive.

What Comprehensive Disease Control Means for IBD, With David Rubin, MD

Rubin's framework, comprehensive disease control, a composite outcome spanning symptoms, objective disease activity, functional health, and quality of life, reflects a shift in how the field defines success in Crohn's disease and ulcerative colitis. As IBD treatments have multiplied, most clinical trial endpoints have stayed centered on the bowel. But Rubin points out that these conditions extend well beyond the intestines.

"We recognize that these conditions affect much more than the intestines, and therefore, in order to take care of people properly who have these problems, we need to be thinking about the whole person," Rubin said.

That whole-person view includes well-established extraintestinal manifestations like joint pain and skin inflammation, but Rubin extends it further to what he calls atypical extraintestinal manifestations: mental health disorders, sexual health, and sleep quality. Patients with IBD have a higher prevalence of anxiety and depression than those without the disease, and Rubin's goal, he said, is "an unrestricted, high quality of life."

Rubin breaks remission into three sequential categories for his patients. The first is symptomatic: no pain, no diarrhea, no bleeding, no urgency.

The second is control of the underlying disease process itself, confirmed through normalized biological markers on scopes, stool tests, or blood tests (in children, growth and development serve as markers). Rubin emphasizes that this second category is not optional. "50% of people who feel well or feel better will still be inflamed, and if you're still inflamed despite feeling okay, you will relapse," he said.

"I want you to feel perfect, but I want it to last forever, and that means we have to control the disease process," Rubin said.

The third category is what Rubin calls functional remission: no joint pain, no skin inflammation, no depression or anxiety, restored sexual health, and the ability to work, travel, go to school, or have children without the disease getting in the way. He describes this as the ultimate goal, but stresses the categories have to be addressed in order.

Comprehensive disease control adds standardized quality-of-life measures to the usual clinical trial endpoints of symptom control and endoscopic or biomarker-based disease control. According to Rubin, this reframing exposes a gap that's easy to miss when only looking at the bowel.

"When you raise the bar, you start to realize that even when you have people whose bowels are perfect, you're not improving their quality of life because you haven't addressed the other issues," Rubin said. "Healing is different than just treating inflammation."

Defining comprehensive disease control for use as a treatment target for ulcerative colitis in clinical practice: international Delphi consensus recommendations. 

Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. 

A gastroenterologist explains why treating bowel inflammation alone isn't enough to call inflammatory bowel disease "controlled."

Optimizing What We Have: Closing the Gap Between IBD Therapies and Patient Outcomes

 treatment armamentarium that now exceeds a dozen approved advanced therapies, outcomes for patients with Crohn disease and ulcerative colitis remain far short of what the field should be achieving.

The problem, according to David Rubin, MD, Joseph B. Kirsner Professor of Medicine, chief of Gastroenterology, Hepatology and Nutrition, and director of the Inflammatory Bowel Disease Center at University of Chicago Medicine, may be less about what clinicians have available and more about how they are using it. Speaking at Digestive Disease Week (DDW) 2026 in Chicago, Illinois, Rubin made the case that rigorous optimization of existing therapies, not just the next pipeline agent, is where the greatest near-term gains lie.

Treat Early to Change the Disease Trajectory

A central theme of Rubin’s discussion is the growing body of evidence supporting early intervention. Traditional clinical trials often enroll patients with long-standing disease, frequently 7 to 10 years in duration, who have already cycled through multiple therapies. As a result, reported remission rates of 20%-30% may underestimate what is achievable in earlier disease.

“We’ve learned that we can achieve 80% remission rates in Crohn’s disease when we treat earlier,” Rubin said.

These findings, supported by emerging real-world and trial data, suggest that early use of advanced therapies may fundamentally alter disease course. This paradigm shift aligns with broader trends in IBD management, where early disease control is increasingly viewed as critical to preventing irreversible bowel damage.

Optimizing Existing Therapies Before Seeking New Ones

While innovation continues across the IBD pipeline, Rubin emphasized that substantial gains can still be made by optimizing current therapies. One common pitfall is inadequate induction dosing, particularly when intravenous induction and subcutaneous maintenance require separate authorization processes.

“If you don’t induce properly, you’re not going to gain control of a hot, inflammatory bowel,” he noted.

Therapeutic drug monitoring also plays a role, though its evidence base remains strongest for anti-TNF agents. In patients losing response, dose optimization may be appropriate, but Rubin advised limiting attempts to recapture response. If efficacy is not regained after several cycles, switching to a different mechanism of action is often more effective than cycling within the same class.

A Structured Approach to Loss of Response

Rubin outlined a practical framework for evaluating patients who are not responding to therapy. First, clinicians must confirm active inflammation, as symptoms alone may reflect alternative processes such as strictures, bile acid diarrhea, or motility disorders. Next, infection, particularly 

Only then should attention turn to the therapy itself. “Where is the drug?” Rubin asked, highlighting factors such as adherence, drug clearance, and delivery challenges. For example, patients with high inflammatory burden or low albumin may experience increased biologic clearance, while those with altered gastrointestinal anatomy may have impaired absorption of oral agents.

Proactive Monitoring and Treat-to-Target Strategies

Another key message is the need to shift from reactive to proactive care. Treat-to-target strategies, supported by biomarkers like fecal calprotectin and C-reactive protein, as well as endoscopy and intestinal ultrasound, are increasingly recognized as essential for optimizing outcomes.

Of note, Rubin stressed that the goal is not perfection, but meaningful disease control and improved quality of life. Overreliance on corticosteroids, for example, remains a persistent issue despite evidence that many patients can achieve remission without them.

With appropriate early treatment, proactive monitoring, and thoughtful optimization, Rubin believes outcomes in IBD can improve significantly, even without new therapies.

“If we have informed clinicians, we have a motivated patient population, we have access to the available therapies, and we optimize those therapies properly, we'll end up with most patients achieving remission with what we already have,” he said. “Innovations are needed, and we still want to find cures, but what we have now, if we do it with the best approach that we've learned, we can do a lot better for many people.”

Editors’ note: Rubin reports relevant disclosures with AbbVie, Abivax SA, Bristol-Myers Squibb, Celltrion, Eli Lilly & Co., Genentech (Roche) Inc., Johnson & Johnson, Merck & Co., and others.

Early Biologic Treatment for Inflammatory Bowel Disease: Drugs

. Canadian Agency for Drugs and Technologies in Health; 2024. https://www.ncbi.nlm.nih.gov/books/NBK609613/ 

Appiah JK, Hayat U, Garg N, et al. Emerging therapies in inflammatory bowel disease: a comprehensive review. 

. 2025;14(17):6119. doi:10.3390/jcm14176119

Despite a growing armamentarium of approved IBD therapies, outcomes remain suboptimal. Rubin explains how earlier treatment and smarter optimization can close the gap.