Symptoms and inflammation do not always move together in inflammatory bowel disease (IBD), and for Jordan Axelrad, MD, MPH, co-director of NYU Langone's Inflammatory Bowel Disease Center, that disconnect shapes nearly every conversation he has with patients who call in feeling unwell.

"Symptoms do not always correlate with objective inflammatory activity," Axelrad told HCPLive in an interview.

Check Out More of Our Interview With Axelrad Here:

Why Symptoms Alone Don't Confirm a Flare

Patients often reach out reporting acute symptoms and asking for prednisone, assuming a flare is underway. Axelrad said it's important for patients to understand that a symptom flare doesn't always line up with actual disease activity, which is exactly why an objective check is needed before assuming the worst.

"That may require laboratories, 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," he said. The specific combination depends on the patient, but the goal is the same across the board: replace a subjective symptom report with objective evidence before deciding how to act on it.

"Having these objective markers of inflammatory activity help us differentiate symptom exacerbation or an infectious etiology from flare of underlying IBD," Axelrad said. Those distinctions, he noted, are managed very differently.

Treat-to-Target as a Shared Framework

"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," Axelrad said. That means setting expectations up front: symptomatic improvement within a couple of weeks to months, biomarker improvement on a similar timeline, and longer-term endoscopic, or in Crohn's disease sometimes radiographic, improvement as the ultimate target.

"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," he said.

"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 towards optimizing that therapy to meet our treat-to-target goals," Axelrad said. That variability is precisely why the objective checkpoints matter: without them, a partial responder and a non-responder can look identical from the symptom picture alone.

Counseling Patients as a Physician Who Has Crohn's Disease

"I think patients find comfort in recognizing that I'm someone who's also used the medications that I'm talking about with patients," Axelrad said. He lives with Crohn's disease himself, and said that for a disease that often affects younger people, moving to a long-term infusion or injectable therapy is a major modification to a patient's life. That shared experience shapes what he listens for in a visit, since patients rarely lead with questions about how fast a drug works.

"Patients oftentimes don't come to the office saying, how quickly can I feel better? They're usually much more concerned about the side effect profile and the long-term interruption of these medications in their lives," he said.

Having sat on the other side of that conversation himself, Axelrad said he's able to meet those concerns directly rather than defaulting to reassurances about efficacy alone.

"Having that personal experience I think really gives patients calm and more confidence in making these decisions together as far as medication selection," Axelrad said.

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

References

1. National Institute of Diabetes and Digestive and Kidney Diseases. Crohn's disease. NIDDK. Reviewed July 2024. Accessed August 18, 2026. https://www.niddk.nih.gov/health-information/digestive-diseases/crohns-disease

2. Crohn's & Colitis Foundation. What are the early indicators of Crohn's disease and ulcerative colitis, and how are these two diseases different from each other? Crohn's & Colitis Foundation. Accessed August 18, 2026. https://www.crohnscolitisfoundation.org/blog/ulcerative-colitis-vs-crohns-disease-what-are-the-early-signs-and-how-are-they-diagnosed