Clinical Review: Guidelines address diagnosis, treatment, and monitoring of IBD in adult patients.
Background & Rationale
Inflammatory bowel disease (IBD), encompassing Crohn’s disease and ulcerative colitis, presents a significant clinical challenge due to its chronic, relapsing-remitting nature. Optimal management requires a comprehensive approach, integrating accurate diagnosis, appropriate pharmacological interventions, and vigilant monitoring for disease activity and complications. Existing guidelines vary in their recommendations, and local expertise may not always be readily available. The authors identified a need for locally relevant, evidence-based guidelines to standardise the medical management of adult patients with moderate-to-severe IBD within the Saudi Arabian healthcare system. These guidelines aim to provide a practical framework for clinicians managing these complex conditions.
Study Design
A consensus-based guideline development process was employed. A multidisciplinary panel of 16 gastroenterologists and colorectal surgeons, representing various regions of Saudi Arabia, participated. The panel conducted a systematic review of international IBD guidelines, including those from the American Gastroenterological Association, the European Crohn’s and Colitis Organisation, and the British Society of Gastroenterology. A modified Delphi method was used to achieve consensus on key recommendations. Statements were initially rated for agreement using a 7-point Likert scale, and subsequent rounds of discussion and re-voting were conducted until a pre-defined level of consensus (at least 80% agreement) was achieved.
Patient Population
These guidelines pertain to the medical management of adult patients (aged 18 years and over) diagnosed with moderate-to-severe IBD, encompassing both Crohn’s disease and ulcerative colitis. The guidelines specifically address patients requiring pharmacological intervention beyond initial aminosalicylate therapy. Patients with very mild disease or those requiring only proctitis-specific treatment were excluded from the scope of these recommendations. The target population is representative of IBD patients encountered in the Saudi Arabian healthcare setting, acknowledging potential regional variations in disease presentation and access to care.
Key Findings
The guidelines recommend initial assessment including detailed history, physical examination, endoscopic evaluation with biopsies, and relevant laboratory investigations, including complete blood count, C-reactive protein, albumin, and faecal calprotectin. For moderate-to-severe ulcerative colitis, the panel recommends induction therapy with either intravenous corticosteroids or a biologic agent – specifically, infliximab, adalimumab, or golimumab. Maintenance therapy options include azathioprine, 6-mercaptopurine, or continued biologic therapy. For moderate-to-severe Crohn’s disease, induction therapy options include corticosteroids, anti-tumour necrosis factor (anti-TNF) agents (infliximab, adalimumab, certolizumab pegol), or ustekinumab. Maintenance therapy recommendations mirror those for ulcerative colitis, with azathioprine, 6-mercaptopurine, anti-TNF agents, or ustekinumab considered.
The guidelines address perianal disease in Crohn’s disease, recommending topical corticosteroids and, if unresponsive, consideration of anti-TNF therapy or surgery. Nutritional support, including enteral nutrition, is recommended for patients with active Crohn’s disease, particularly those with malnutrition. Monitoring recommendations include regular clinical assessment, endoscopic surveillance for colorectal cancer in ulcerative colitis (after 8 years of disease duration, with colonoscopy every 1-3 years), and monitoring for drug-related adverse effects.
Discussion
These guidelines provide a structured approach to the medical management of moderate-to-severe IBD, tailored to the Saudi Arabian context. The emphasis on a multidisciplinary approach, comprehensive assessment, and evidence-based pharmacological interventions aligns with international best practices. The inclusion of both Crohn’s disease and ulcerative colitis within a single framework acknowledges the overlapping principles of management while recognising disease-specific nuances. The guidelines address the importance of long-term monitoring, particularly for colorectal cancer risk in ulcerative colitis, and highlight the role of nutritional support in Crohn’s disease.
Safety and tolerability considerations are integrated into the recommendations, with emphasis on monitoring for adverse effects associated with immunosuppressive and biologic therapies. The guidelines acknowledge the potential for variations in clinical practice and encourage individualised treatment plans based on patient-specific factors.
Authors’ Conclusions
The authors conclude that these consensus guidelines represent a practical and evidence-based framework for the medical management of adult patients with moderate-to-severe IBD in Saudi Arabia. They anticipate that implementation of these guidelines will contribute to improved patient outcomes, reduced disease-related morbidity, and enhanced quality of care for individuals living with IBD. The panel recommends regular review and updates to these guidelines as new evidence emerges and clinical practice evolves.
Reference
Mosli MH, Al-Bawardy B, AlAmeel T, et al. Practical guidelines on medical management of adults with moderate-to-severe inflammatory bowel disease. Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2025;25(1):1–18. doi:10.4103/sjg.sjg_277_25.