Inflammatory bowel diseases (IBD) are chronic immune-mediated disorders affecting the gastrointestinal tract. Ulcerative colitis (UC) and Crohn's disease (CD) are the most common IBDs. Patients with IBD typically present with abdominal pain, vomiting, diarrhoea, and in the case of UC, rectal bleeding. In the long term, patients with IBD have an increased risk of cancer. The origins of IBD can be traced to a complex interplay of genetic and environmental factors coupled with abnormal immune responses to microbes in the gut.

According to 2019 estimates, there are about 4.9m people with IBD in the world. Currently, high-income countries in Asia Pacific, North America and Western Europe have the highest age-adjusted prevalence of IBD. While originally considered a disease of the West, incidence in Asia and Africa, as well as among Asian immigrants to western countries, has been rising; Asia, North Africa and the Middle East have seen the highest increase in age-adjusted prevalence over the last three decades.

While mortality rates for IBD are low, morbidity and disability are high. Over a 10-year period, the risk of a colectomy in patients with UC is ~13% and the risk of surgery in patients with CD is ~40%. Extraintestinal manifestations, where the disease affects parts of the body other than intestines, occur in about 17% of patients with UC and 37% of patients with CD, affecting joints, skin, eyes or the liver. Venous blood clots, anaemia, and osteoporosis are more common in patients with IBD. The risk of cancer is increased in IBD—patients with UC have a 2.4-fold higher risk compared to the general population.

The impact of the disease on quality of life and mental health is also significant. Fatigue is a disabling symptom, occurring in ~72% of patients with active disease and almost half of patients in remission. Anxiety and depression occur in ~20% of patients with IBD and are higher in those with active, rather than inactive, IBD. Therefore, early diagnosis and appropriate treatment are crucial to inducing disease remission and reducing disability.

Barriers in the IBD care pathway

Unfortunately, delayed diagnosis remains a common problem due to the lack of awareness and non-specific symptoms of IBD. Specialist evaluation is necessary to confirm the diagnosis, but is often a challenge due to long wait times and geographical barriers. One in four people wait longer than seven and 15 months for a diagnosis of UC and CD, respectively. Delayed diagnosis leads to more severe disease and doubles the patient's risk of intestinal surgery, emphasising the need to ease these bottlenecks and streamline the care pathways.

The last two decades have seen an explosion in the therapeutic arsenal for IBD; the development of biologics and novel oral agents has revolutionised the management of the condition. A sizeable number of patients can achieve mucosal healing and endoscopic remission with these drugs.  These advances have supported improved treatment goals that now include complete clinical, biochemical and endoscopic remission of IBD. The International Organization for the Study of IBD (IOIBD) has established the Selecting Therapeutic Targets in IBD program (STRIDE). The latest STRIDE II guidelines recommend a treat-to-target approach (T2T) for IBD, the long-term goals of which are achieving complete endoscopic remission and normalisation of quality of life.

Though responses to novel agents are encouraging, significant gaps remain. The diversity of agents available for the treatment of IBD lags far behind other inflammatory illnesses like rheumatoid arthritis and psoriasis. Challenges in accessing these drugs, including delays in regulatory approval, reimbursement issues and administrative requirements, are major impediments to therapy. Furthermore, clinical practice varies widely among physicians in terms of patient choice, treatment use, monitoring and escalation. While decreases in hospitalisation and surgery have been observed with the use of biologics in clinical trials, real-world evidence does not consistently corroborate this finding. Suboptimal drug use in the clinical setting may partly explain these findings, suggesting the need for improved dissemination of guidelines. Most importantly, there is a lack of validated predictive markers to identify the optimal novel agent for each patient before commencing treatment. Therefore, drug changes are often required, which can delay recovery and compromise outcomes.

Given the impact of IBD on various facets of patients' lives, multidisciplinary and patient-centric care is critical to improving outcomes. The engagement of specialist IBD nurses has been shown to reduce hospitalisations, and emergency room and outpatient visits, with potential cost savings. Nutritionists and psychologists are key multidisciplinary team members in providing holistic care. However, these professionals are not consistently available in IBD clinics to support patients due to resource and logistical constraints.

Looking forward

Streamlining the care pathway for IBD

Creating awareness among the public is the most crucial step to ensure that patients with symptoms present early to the healthcare system. To facilitate early diagnosis, frontline physicians need to be educated on the red flag symptoms of IBD, and on extraintestinal and other non-specific symptoms that could signal this diagnosis. Using non-invasive tests like faecal calprotectin to rule out IBD in selected patients can reduce the number of specialist referrals and wait times. Access to advanced therapies should be streamlined to ensure patients receive optimal treatment and have greater chances of biochemical and endoscopic remission. Treatment should be offered by a multidisciplinary team with specialist nurses, nutritionists and psychologists. Shared decision-making should be supported to ensure that the patient's personal treatment goals are met.

Engaging technology

Technology should be harnessed to build capacities and capabilities in health systems, improve patient-centric care and reduce disease burden on patients. The explosion of mobile health apps in IBD has helped with providing educational materials, increasing disease awareness, better treatment monitoring and improving access to psychosocial support. Investments should be made to facilitate information exchange between these apps used by patients and electronic health records to ensure that this information can be easily used for patient care. Telehealth visits for selected patients can improve patient experience, as well as reduce health system burden and costs.

Investing in research

Despite the advent of many effective novel agents, there is a dearth of predictive models that can identify the most suitable therapies for each patient. Research into precision medicine for IBD, including predictive models and artificial intelligence (AI)-based multi-omics analysis, should be supported. The development of non-invasive modalities to assess treatment response and mucosal healing will lower health system burden and improve patient compliance with the T2T approach. Investments should continue to be made in developing newer therapies with better response rates. Fundamental research into the prevention of IBD is still the ultimate goal.

As health systems face growing waitlists, human resource constraints and a plethora of new medical conditions post-pandemic, there is an imminent need to optimise care for IBD to improve patient outcomes and reduce the system-wide burden. Such efforts should be combined with capacity building and the development of cross-cutting solutions that can eventually be expanded to other chronic diseases.