Victor Chedid, MD, MS, is an assistant professor of medicine and director of the IBD Pride Clinic at Mayo Clinic.

Victor Chedid, MD, MS

Beyond Anti-TNF: An Evolving IBD Treatment Landscape, With Victor Chedid, MD, MS

 is in the midst of a significant period of change. New therapeutic targets are advancing through clinical trials, treatment goals are being redefined, and the question of sequencing therapies is becoming both more nuanced and more pressing.

Victor Chedid, MD, MS, aan assistant professor of medicine and director of the IBD Pride Clinic at Mayo Clinic, spoke with 

 at Digestive Disease Week (DDW) 2026 about what he sees as some of the most meaningful shifts in IBD care, along with their meaning for clinicians managing patients with moderate-to-severe disease.

A Toolbox That Looks Different Than It Did a Few Years Ago

Historically, anti-tumor necrosis factor (anti-TNF) agents were once the primary option for patients who needed advanced IBD therapy. Now, interleukin-23 inhibitors are approved and widely used, while agents targeting additional pathways, including TL1A, are in development, with early data suggesting potential anti-fibrotic effects in addition to anti-inflammatory activity.

That last point may be particularly relevant for patients with Crohn's disease who have developed stricturing complications. Prior IBD therapies have largely focused on controlling inflammation. Therefore, an agent that could also address fibrosis would represent a meaningfully different type of intervention.

"The toolbox for the providers taking care of people with IBD has grown dramatically over the past few years," Chedid said. "We've seen a lot of novel therapeutics and agents that are on the market that go beyond just the older anti-TNF, we're seeing agents that target interleukin-23, we're seeing targets of anti-TL1A antibodies that have potential for anti-fibrotic [activity], which is very exciting. We've not seen anti-fibrotics in the IBD toolbox before."

Meanwhile, Chedid has witnessed the expansion of drug delivery options over the years. Subcutaneous formulations, auto-injectors, on-body devices, and oral small molecules are now available or in development, giving patients and clinicians more flexibility when it comes to treatment preferences and practical adherence considerations.

The Shift Toward Deep Remission — and What That Requires

One of the more significant conceptual changes in IBD management is the move away from symptomatic response as a sufficient endpoint. According to the 2025 American Gastroenterological Association (AGA) clinical practice guideline for moderate-to-severe Crohn's disease, the goal of treatment should be deep remission, meaning mucosal and histologic healing, not just the resolution of symptoms.

This has practical implications for how clinicians monitor patients, explains Chedid. Non-invasive markers like fecal calprotectin and C-reactive protein are being increasingly used as ongoing indicators of mucosal activity, alongside more timely endoscopic reassessment to confirm whether treatment targets are being met.

It also has implications for when to start high-efficacy therapy. The updated AGA guidance moves away from the step-up approach, initiating advanced biologics only after simpler therapies have failed, in favor of earlier use of high-efficacy agents.

"Early use of high efficacy therapies has shown more and more benefit for patients with IBD," Chedid said. "We got to think of the right drug at the right time."

With more approved agents available, clinicians are now navigating decisions that did not exist a decade ago. Choosing among therapies with different mechanisms, deliveries, safety profiles, and cost considerations requires a structured approach, one accounting for disease phenotype, comorbidities, patient preference, and practical access.

Therapeutic drug monitoring (TDM), measuring trough drug levels prior to the next dose, is one tool that can help individualize biologic dosing. Beyond its clinical utility, Chedid noted that TDM data can also support insurance appeals for dose escalation, a practical consideration in real-world practice.

Combination Therapy: Early Data, but Worth Watching

One area generating interest and still in early stages is the concept of combining biologic agents with different mechanisms of action. Data presented at DDW from the phase 2b DUET-CD trial examined JNJ-78934804 (JNJ-4804), a fixed-dose co-antibody combining an IL-23 inhibitor (guselkumab) and an anti-TNF agent (golimumab), in 693 patients with moderate-to-severe Crohn's disease who had inadequate response to at least one prior systemic therapy. Investigators described the results as promising, particularly in the most treatment-refractory subgroup, but phase 3 trials and FDA review would be necessary before such an approach could be considered for broader use.

"This exciting phase of thinking about combination therapies, seeing them in clinical trials and in the pipelines — that's an exciting future," Chedid said, while noting that the data remain preliminary. "Mind you, it's a phase 2 trial still, so it's not going to be applicable to the general public quite yet."

Looking Ahead: Matching the Right Therapy to the Right Patient

Clinicians are working toward a more precise understanding of which patients are likely to respond to which therapies before treatment begins. Multi-omic profiling, integrating genomic data with endoscopic, radiologic, and laboratory phenotyping, may eventually provide that kind of predictive information, though that application remains largely in development.

For now, Chedid emphasized that decision-making should be grounded in a combination of clinical evidence, careful disease characterization, and shared decision-making with the patient. This includes factoring in disease severity along with lifestyle, delivery preference, and individual treatment goals.

"We're asking: what is the mechanism of action of the drug, what is the phenotype the patient is experiencing, what are the comorbidities?" he said. "All of that falls into the shared decision making."

Editor’s Note: Chedid reports relevant disclosures with Pfizer and Takeda.

Scott FI, Ananthakrishnan AN, Click B, et al. AGA living clinical practice guideline on the pharmacologic management of moderate-to-severe Crohn's disease. 

. 2025;169(7):1397-1448. doi:10.1053/j.gastro.2025.09.038

Sands BE, et al. Efficacy and safety of the first co-antibody therapy, JNJ-78934804, in patients with moderately to severely active Crohn's disease refractory to systemic therapies [abstract 979f]. Presented at: Digestive Disease Week 2026; May 2-5, 2026; Chicago, IL.

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Chedid, MD, MS, explains the evolving therapeutic IBD landscape, including new data from DDW 2026. 

Persistent Symptoms, Equity Gaps, Pushing For Whole-Person IBD Care, With Victor Chedid, MD, MS

 is increasingly viewed as a necessary milestone, but may not be sufficient. Even after inflammation has been controlled, a meaningful number of patients continue to experience symptoms. Meanwhile, a separate but related challenge is disproportionate access to the therapies needed to reach remission in the first place across patient populations.

Victor Chedid, MD, MS, an assistant professor of medicine and director of the IBD Pride Clinic at Mayo Clinic, spoke with 

 2026 about how he approaches these problems, along with his belief that expanding the definition of personalized medicine beyond molecular targets is the future of IBD care.

A patient with confirmed mucosal remission who continues to report diarrhea, pain, or fatigue is a common experience in IBD care. The clinical instinct to escalate or switch biologic therapy can be counterproductive in this setting. According to Chedid, this is not because it is unreasonable, but because it may not address the driving symptoms.

"Whenever a hurricane hits a town, the hurricane is actively damaging the town during the active storm, and as it passes, it goes away, but then we are left with the damage that that hurricane left behind, and the city or the town would be working on rebuilding over time," Chedid said. "Inflammation in inflammatory bowel disease, in Crohn's disease, ulcerative colitis, is like the hurricane that just hit. As the inflammation subsides and we are able to get the inflammation under control, we are left with the damage that that inflammation has caused that will take time to be rebuilt."

The underlying mechanisms can be varied, such as residual intestinal barrier dysfunction, gut microbiome disruption during recovery, bile acid malabsorption, pelvic floor dysfunction, and neuro-visceral hypersensitivity. Thesea re among the functional contributors that may explain ongoing symptoms in a patient who is, by objective measures, in remission. Each of these has a distinct, and potentially targetable mechanism.

Chedid's approach to IBD care management begins with confirming remission, using objective biomarkers rather than symptom report alone. Once that is established, the workup pivots toward identifying specific functional drivers.

Bile acid testing may reveal malabsorption as a cause of chronic diarrhea, which can be addressed pharmacologically. Anorectal manometry and pelvic floor evaluation may uncover dysfunction amenable to biofeedback. Neuro-visceral hypersensitivity is increasingly recognized as a distinct entity within disorders of gut-brain interaction, and may respond to neuromodulatory agents.

Clinicians should be wary of defaulting to an irritable bowel syndrome (IBS) and IBD overlap, explains Chedid.

"No patient should be dismissed with their symptoms," he said. "Many times when a patient presents with persistent symptoms, their doctors end up cycling through the different IBD biologics, although there is no active inflammation. Doing that quick transition from one IBD drug to another will reduce the toolbox of actual IBD therapies we have for that patient, and will not be addressing the root cause."

Access Disparities Remain a Real Clinical Problem

The IBD field has moved toward earlier initiation of high-efficacy biologics as a standard of care, but that recommendation is dependent on patient characteristics. Patients from racial and ethnic minority groups, as well as those from other marginalized communities, often face structural barriers to subspecialty care and to the advanced therapies that guidelines now recommend up front.

"People from minoritized backgrounds might have less insurance coverage or less access to such advanced therapies," he said, "so they might be at a disadvantage and end up with poor outcomes just because of lack of access."

Contributing to this gap are insurance hurdles, geographic barriers to IBD subspecialists, and cultural factors that shape care-seeking and patient-provider communication. For Chedid, addressing equity is a major piece in the precision medicine agenda.

That also means rethinking how clinicians approach the patient encounter itself. Chedid described a move away from cultural competence as a framework and toward cultural humility. For example, clinicians can have genuine curiosity about the individual patient, their intersectional identities, their values, and their experience of care.

Digital Tools and AI: Useful, With Caveats

Remote monitoring technologies, including telemedicine, symptom-tracking applications, and wearable biosensors, are beginning to provide more continuous data on treatment response, with the possibility of earlier detection of disease flares. AI-based decision support tools are being developed to help synthesize complex datasets, from lab trends to endoscopic reports, to assist with diagnosis, disease activity scoring, and therapeutic sequencing.

"We got to make sure that as we're developing them, we're always inclusive of all populations," he said, "so that we are not missing a certain group and furthering the disparities we've been talking about."

He also emphasized the importance of robust data privacy protections, particularly given existing mistrust among some communities regarding how health information is used.

Putting It Together: Personalization Beyond the Prescription

The personalized medicine framework in IBD has tended to center on biomarkers, genomics, and therapeutic targets. Chedid's view is that the framework needs to extend further towards the patient's goals, preferences, lifestyle, and identity.

"Personalization is not only about the drugs that you choose," he said. "We engage the patients as partners in their own care. We have to make sure that we're aligning their treatment choices with their lifestyles, their life goals, their preference."

A clinician’s treatment goal might be a fecal calprotectin below a certain threshold, while the patient's goal might be running a marathon. Chedid emphasizes that both are important in modern IBD care, especially finding a treatment approach and communicating clearly about what each goal requires.

Managing IBD comprehensively also means not treating it in isolation. Chedid described a model of care that includes IBD-trained dietitians, GI psychologists, pelvic floor specialists, mental health providers, colorectal surgeons, IBD pharmacists, and advanced practice nurses, describing IBD care as taking a village.

Mak JWY, Mak TN, Ng SC, et al. Inequalities in healthcare access, experience and outcomes in adults with inflammatory bowel disease: a scoping review. 

. 2024;18(12):1989-2004. doi:10.1093/ecco-jcc/jjae113

Saleh M, et al. Racial disparities in utilization of medications and disease outcomes in inflammatory bowel disease patients. 

. Published 2024. doi:10.1186/s12876-024-03196-8

Sinagra E, Rossi F, Raimondo D, et al. Irritable bowel syndrome in inflammatory bowel disease: an evidence-based practical review. 

. 2025;15(1):116. doi:10.3390/jcm15010116

Chedid describes the future of personalizing IBD care based on patient characteristics. 

Victor Chedid, MD, MS

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