Jordan E. Axelrad, MD, MPH, treats patients with Crohn's disease and ulcerative colitis while managing Crohn's disease himself—an experience he says gives patients real comfort as they face major, long-term treatment decisions.

In an interview with HCPLive, the co-director of NYU Langone's Inflammatory Bowel Disease Center discussed how he approaches first-line therapy selection, the role of treat-to-target in day-to-day management, and how that personal experience shapes the way he counsels patients.

Q&A: How a Physician With Crohn's Disease Approaches IBD Care

HCPLive: With so many mechanisms of action now available for Crohn's and ulcerative colitis, how are you approaching first-line therapy selection and sequencing after failure, and what factors most influence that decision?

The first thing I'm always doing when I meet with a patient is assessing disease activity, so their snapshot of what's going on right now, and disease severity—what's their risk of disease progression and disease prognosis over time. That's a bit more relevant for Crohn's disease, but certainly is relevant for ulcerative colitis as well. Then I'm also having shared decision-making with the patient, understanding what's important to the patient, whether patients can achieve an infusion medication, whether they will be able to take an injectable medication, or whether they only want to take an oral medication. All of that's going to influence the decision-making that we'll make together.

Once we sort of meet in the middle of what's important to the patient and how severe and active their disease is, which also influences drug selection, then we make a decision together. Typically, after patients fail an initial therapy—and of course you want to be making sure that objectively you're assessing for failure with objective biomarkers or endoscopy—then typically we use medications that have evidence in a second or third-line use. In today's world, those medications are primarily anti-TNF agents and JAK inhibitors. That's usually what we'll use after patients have a primary therapeutic failure to an alternative agent, but that activity and severity is really important for assessing what patients will need.

HCPLive: How has the treat-to-target approach changed your day-to-day management of IBD patients? What combination of clinical, biomarker, and endoscopic data do you rely on to confirm a patient is truly in remission?

I have the treat-to-target conversation with all of my patients so that my patients and I are on exactly the same page when we're discussing therapy initiation. I meet them exactly where they are—I expect them to start feeling better within a couple of weeks to months, I expect their biomarkers to improve within a couple of weeks to months, and then I expect long-term improvement in their endoscopic appearance, or radiographic appearance in Crohn's disease, over time, and that may be a longer-term treatment target. I'm having that conversation with patients so they can understand exactly the expectations of when they may start feeling better, and also what I'm looking for to confirm objectively that patients are doing better.

Those assessments may actually vary from patient to patient, but generally we want to see meaningful improvements in endoscopic response within 6 months to 1 year, and we're adjusting treatment based on treat-to-target if we're not achieving those important goals. Everyone's a little bit different, so there may be instances where patients have no response to an individual therapy, in which case we may switch to a completely different mechanism, whereas many patients may have partial response and we may work toward optimizing that therapy to meet our treat-to-target goals.

HCPLive: As new IBD therapies continue to reach approval, how do you decide where a new drug fits relative to established options, and what unmet needs are you still looking for these therapies to address?

We still have a huge amount of unmet need in inflammatory bowel disease. Meaningful disease remission, as far as endoscopic remission, is difficult to achieve with our current therapeutic arsenal. Additionally, there are many subtypes of Crohn's disease, for example, fistulizing Crohn's and stricturing Crohn's, where medications work far less well compared to other types of Crohn's and ulcerative colitis, so there's a huge amount of therapeutic unmet need.

Anytime a new medication comes to market, you always want to know what's the value of this new medication. Is it a route of administration? Is it safety? Is it efficacy? Does it work in unique subtypes? Where is that value? That's how I make decisions about integrating new therapies into my treatments. If a new drug that comes to market works particularly well in patients who have failed other therapies, that's a great addition, because these are patients who have even more unmet need, and that's really important in evaluating drugs as they come to market. Despite all that, there's still a huge amount of unmet need, and we're still desperately searching for new therapies, or maybe combinations of therapies, that move the needle toward a greater proportion of patients achieving meaningful disease outcomes.

HCPLive: IBD symptoms can overlap with strictures, infection, and other complications. What's your clinical approach to working up a patient who isn't responding as expected before assuming it's simply active disease?

Symptoms do not always correlate with objective inflammatory activity, and that's really important to why patients and providers have to be on the same page about the workup required anytime someone is symptomatic. Often, patients will reach out to me saying, I'm not feeling well, I'm having acute symptoms, I need prednisone or what have you. It's important that patients understand that symptoms not correlating with disease activity means we need to check objective markers.

That may require laboratories and biomarkers, including C-reactive protein and fecal calprotectin. It may require endoscopy to more objectively assess the status of the mucosa, and in patients with Crohn's disease, may often require cross-sectional radiography or intestinal ultrasound. Having these objective markers of inflammatory activity helps us differentiate symptom exacerbation or an infectious etiology from a flare of underlying IBD, because all of those are going to be managed very differently.

HCPLive: As someone living with Crohn's yourself, how has that personal experience shaped the way you counsel patients through diagnosis, treatment decisions, and the long-term realities of managing IBD?

I think patients find comfort in recognizing that I'm someone who's also used the medications that I'm talking about with patients. Keeping in mind that IBD is a disease that affects younger people, moving to a medication that may be infusion or injectable, and that is long-term, is a major step and a major modification to many patients' lives. Having that comfort with patients, knowing that I've been through that process and understand what it's like, can be really, very helpful.

Patients oftentimes don't come to the office asking how quickly they can feel better. They're usually much more concerned about the side effect profile and the long-term interruption of these medications in their lives. Having that personal experience really gives patients calm and more confidence in making these decisions together when it comes to medication selection.

Editor’s Note: Axelrad reports relevant disclosures with AbbVie, Abivax, Adiso, BioFire Diagnostics, bioMérieux, Bristol Myers Squibb, and others.

References:

1. 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. Gastroenterology. 2021;160(5):1570-1583.

2. Lichtenstein GR, Loftus EV Jr, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG clinical guideline: management of Crohn's disease in adults. Am J Gastroenterol. 2025;120(6):1225-1264.