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Ulcerative colitis Learning Zone
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Treatment decision-making for ulcerative colitis

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Read time: 30 mins
Last updated:1st May 2024
Published:21st Sep 2023

Treatment decision-making for ulcerative colitis

In this section

Timely UC treatment progression

Test your knowledge on ulcerative colitis

Challenge your knowledge by answering four questions in this short quiz on ulcerative colitis (UC). Your answers will also help us to measure the effectiveness of the medical education on Medthority.

Meet Jerome

Jerome, 33 years of age, presented to his GP with fatigue, bloody stools, diarrhoea and faecal incontinence, and was subsequently diagnosed with moderate-to-severe UC.

Test your knowledge on ulcerative colitis

Challenge your knowledge by answering four questions in this short quiz on ulcerative colitis (UC). Your answers will also help us to measure the effectiveness of the medical education on Medthority.

Meet Jerome

Jerome, 33 years of age, presented to his GP with fatigue, bloody stools, diarrhoea and faecal incontinence, and was subsequently diagnosed with moderate-to-severe UC.

1. Aside from corticosteroids, which of the following treatment options are recommended for inducing remission in moderate-to-severe UC, according to current European and US guidelines for UC management?
2. Jerome has asked for information about more recently approved UC treatments, such as the IL-23 inhibitor mirikizumab, JAK inhibitors upadacitinib and filgotinib, and the S1PR modulator ozanimod. In the clinical trials that supported regulatory approval of mirikizumab, upadacitinib, filgotinib and ozanimod for the treatment of moderate-to-severe UC in Europe and/or the US, the primary endpoint was:
3. What are key considerations that can inform whether recently approved biologics and targeted small molecules could be appropriate for Jerome (aside from disease severity and extent, and the regulatory-approved indications for each treatment)?
4. What is the primary aim of developing new treatments to help address unmet needs in moderate-to-severe and refractory UC?
How confident do you feel about managing a similar patient case?
Permission to contact. Please tick this box if you are willing for us to contact you at a later date to request more detailed feedback.

The importance of timely treatment progression

What impact can timely symptom control have on people with ulcerative colitis (UC)? Join Dr Hanauer for a discussion of the burden of gastrointestinal symptoms on the daily lives of people with UC and why managing the condition is “both a sprint and a marathon”.

What is timely UC treatment progression?

Systemic corticosteroids are among the first-line options for inducing remission in people with moderate-to-severe UC but are not effective for maintaining remission1. Long-term use and overuse of corticosteroids are associated with significant safety concerns, and guidelines recommend restricting their use to a maximum of 3 months1. Delays in treatment escalation to steroid-sparing medications can have an adverse impact on outcomes for people with UC2,3.

An important goal of UC treatment is to achieve and maintain corticosteroid-free remission2. However, after initial treatment with corticosteroids, around two-thirds of patients will require re-introduction of corticosteroids and one-third will develop steroid-dependence over time2.

In people with Crohn’s disease, early initiation of biologics is clearly beneficial in slowing disease progression1,4. By contrast, this has been less well evaluated in UC and it remains debatable whether early escalation to advanced therapies is similarly beneficial in people with UC1,4.

The timing of escalation to advanced therapies in people with UC requires balancing the potential benefits of stringent disease control at the expense of exposure to increased toxicity versus potential long-term harms of imperfectly controlled inflammation4

For people with UC in whom medical treatment has failed and colectomy is indicated, delayed surgery has been associated with higher rates of post-operative complications3. As such, timely treatment decision-making is important to prevent delays in surgical intervention while unnecessarily prolonging treatment with ineffective medicines in these patients3.

Therefore, it is important to assess response to treatments within an optimal time frame and consider treatment escalation when the response is inadequate2,3,5.

Timely assessment of response to treatment

Recommended time frames to assess clinical response to UC treatment are currently based on expert opinion, as there are limited data available in this area6.

For mild UC, it is recommended to assess response to induction therapy within 6 weeks of commencing treatment5.

For moderate-to-severe UC, recommended time frames to assess clinical response to treatments are summarised in Figure 1. If a response is observed to a tumour necrosis factor alpha (TNF-α) inhibitor, dose optimisation is recommended3. In cases of inadequate response, assess the need to escalate treatment3. After failure of initial treatment with a TNF-α inhibitor, treatment escalation may involve increasing the dose, reducing the dosing interval, or switching within or out of class, depending on the clinical context3.

Figure 1. Timely assessment of treatment response in moderate-to-severe ulcerative colitis2,3,5-7. 5-ASA, 5-aminosalicylate; TNF-α, tumour necrosis factor alpha. *Or arrange hospital treatment, if indicated2.

Figure 1. Timely assessment of treatment response in moderate-to-severe ulcerative colitis2,3,5-7. *Or arrange hospital treatment, if indicated8. 5-ASA, 5-aminosalicylate; TNF-α, tumour necrosis factor alpha.

Monitoring and review of treatment

All people with inflammatory bowel disease (IBD) who start on immunosuppressive treatment should receive written information on the benefits, risks, side effects and monitoring of treatment3.

Considering the chronicity of UC and the requirement for long-term treatment, it is also important to monitor for disease-related and treatment-related complications5. A review of treatment should be undertaken at least annually for all people with UC taking immunomodulators or biologics3. This provides an opportunity to3:

  • Reassess response and long-term clinical remission
  • Re-evaluate adverse effects of treatment
  • Consider any changes to patient circumstances
  • Consider whether to continue, optimise or cease treatment

In addition, more frequent monitoring for side effects is recommended for specific treatments3. For example, it is recommended to monitor for side effects of thiopurines at least every 3 months. If side effects are experienced, potential strategies to address them include splitting or lowering the medication dose or switching to a different medication3.

Risks associated with steroid complacency

Corticosteroids are effective for inducing clinical remission in UC, but evidence does not support a role for corticosteroids in maintaining remission or preventing relapse1,3.

Prolonged treatment with high-dose corticosteroids is associated with diminishing chances of achieving remission and, in those who do respond, evidence suggests over 20% will become corticosteroid-dependent within 1 year3

The use of corticosteroids is also limited by their safety profile, with particular concerns around long-term use1,5. Prolonged use of corticosteroids (i.e., continuous treatment for >3 months) is associated with side effects such as increased infection risk, osteoporosis, suppression of the hypothalamic–pituitary–adrenal axis, diabetes, weight gain and cardiovascular disease3.

To minimise risks of corticosteroid use in UC, it is important to:

  • Restrict courses of corticosteroids to a maximum of 3months1
  • Clinically assess response to induction therapy with oral corticosteroids within 2weeks, to identify non-responders promptly and avoid delayed escalation of treatment7
  • Monitor corticosteroid exposure in people with UC1 and avoid repeated doses of corticosteroids, even in people with mild-to-moderate UC5
  • Consider escalating treatment to a corticosteroid-sparing agent (thiopurines, biologics, targeted small molecules) if more than one course of systemic corticosteroids is required within 1year, or if disease flares are experienced upon corticosteroid tapering1,5

Second-generation corticosteroids with low bioavailability, such as the colonic-release formulation budesonide multimatrix (MMX), have been introduced to help address the limitations of corticosteroid treatment in mild-to-moderate UC1,8. Although second-generation corticosteroids may have a reduced risk of side effects, they are more costly than oral prednisone9.

UC treatment sequencing and switching

Expert insights into treatment selection and sequencing

Considerations for appropriate treatment selection

Dr Tim Raine provides an overview of his thought process when addressing active symptoms in people with ulcerative colitis (UC), including consideration of extraintestinal manifestations, patient preferences and tailoring treatment to each person’s individual needs and risk profile.

Small molecule treatments or biologic treatments choosing the appropriate for a given patient

Professor Stephen Hanauer describes limitations of clinical evidence for the relative position of UC treatments and explores the importance of considering each patient’s individual risk–benefit profile for treatments with different mechanisms of action.

UC treatment selection

Key considerations when selecting UC treatments include disease severity, extent and prognosis, and approved treatment indications, alongside the needs and preferences of the patient3,5,11 (Figure 2). While the place in therapy for UC treatments is generally stratified across guidelines by disease severity and prior treatment exposure, disease extent can influence the optimal route of drug administration1.

Figure 2. Treatment selection in ulcerative colitis1,2,5,11. UC, ulcerative colitis

Figure 2. Treatment selection in ulcerative colitis1,3,5,11. UC, ulcerative colitis.

What key factors influence individualised treatment selection in UC?

Various patient- and disease-related factors influence treatment selection in UC (Table 1).

Table 1. Key factors that can influence individualised treatment selection in ulcerative colitis1,8,12-15. Refer to the respective product information for details on restrictions for UC treatments in specific populations. ASA, aminosalicylates; EMA, European Medicines Agency; FDA, US Food and Drug Administration; JAK, Janus kinase; MMX, multimatrix; S1P, sphingosine 1-phosphate; TNF-α, tumour necrosis factor alpha; UC, ulcerative colitis.

Patient characteristic Influence on treatment selection
Disease severity Mild-to-moderate UC
• Conventional therapies are recommended
• Localised treatments may be considered according to disease extent

Moderate-to-severe UC
• Biologics and targeted small molecules are approved
   by the EMA and FDA for this population
• Systemic treatments, including biologics and targeted
   small molecules, are recommended by guidelines
Prior treatment exposure Influences
• Eligibility for EMA/FDA-approved biologics 
   and targeted small molecules
• Likelihood of achieving a response to subsequent treatments
• Choice of subsequent treatments
Disease extent Influences the optimal route of drug administration: localised treatment may be trialled before the use of systemic therapies, based on disease extent and severity
• In proctitis or distal colitis, topical treatments are often used
• In mildly active left-sided UC, rectal 5-ASA enemas or
  colonic-release corticosteroids (such as budesonide MMX)
  may be considered

Although topical treatments may have fewer systemic side effects, this route of administration may be poorly accepted by some patients
Comorbidities Vedolizumab may be preferred because of its gut selectivity
Older patients Organ-selective treatments may be preferred to systemic treatments, considering the higher risk of opportunistic infections with systemic therapy

Vedolizumab may be preferred because of its gut selectivity
Concomitant extraintestinal manifestations Systemic treatments or combination approaches may be preferred, depending on the type of extraintestinal manifestation

TNF-α inhibitors may be preferred for patients with concomitant articular, ocular or dermatological manifestations
Pregnancy For active disease or difficult-to-control UC, continue treatment with a TNF-α inhibitor or other biologic

If experiencing a flare, manage according to current guidelines for non-pregnant patients, with 5-ASA, steroids, ciclosporin, TNF-α inhibitors, ustekinumab or vedolizumab

Initiating monotherapy with a thiopurine is generally not recommended (slow onset of action, potential risk of adverse events)

JAK inhibitors and S1P receptor modulators should be avoided during pregnancy

UC treatment sequencing

The sequencing of treatments for moderate-to-severe UC is summarised in Figure 3, according to indications approved by the European Medicines Agency (EMA) and/or US Food and Drug Administration (FDA).

Figure 3. Treatment sequence for moderate-to-severe ulcerative colitis, according to indications approved by the EMA and FDA16-33. 6-MP, 6-mercaptopurine; AZA, azathiopurine; EMA, European Medicines Agency; FDA, U.S. Food and Drug Administration; TNF-α, tumour necrosis factor alpha; UC, ulcerative colitis. *Also approved for paediatric patients with UC16,17,22,23. Approved indications were last

Figure 3. Treatment sequence for moderate-to-severe ulcerative colitis, according to indications approved by the EMA and FDA16-33. *Also approved for paediatric patients with UC16,17,22,23. Approved indications were last verified in March 2024. 6-MP, 6-mercaptopurine; AZA, azathiopurine; EMA, European Medicines Agency; FDA, US Food and Drug Administration; TNF-α, tumour necrosis factor alpha; UC, ulcerative colitis.

Which patients might benefit from early treatment escalation to TNF-α inhibitors?

Although the optimal time point to initiate treatment with tumour necrosis factor alpha (TNF-α) inhibitors in UC has not yet been defined16, it has been proposed that people with UC characteristics predictive of severe or complicated disease may benefit from early treatment escalation. These characteristics include1,6:

  • Young age at first diagnosis (<40 years old)
  • Extensive disease
  • High inflammatory burden

It has been suggested that treatment with intensive therapy from an earlier time point may help to prevent disease progression and subsequent disease complications6. However, clinical benefits from early treatment escalation to TNF-α inhibitors have not yet been demonstrated in UC clinical trials1.

UC treatment switching

In patients who are experiencing inadequate treatment response or treatment failure, it is important to consider alternative options3. Switching between UC treatments may be considered in cases of inadequate response, failure or loss of response to an initial or subsequent treatment3,5. In cases of inadequate or lost response, switches may be within class or out of class, depending on the situation. These decisions can be informed by clinical context, serum drug concentrations and anti-drug antibody concentrations3.

For those on TNF-α inhibitors, treatment failure can be divided into two categories3:

  • Primary non-response, which involves an inadequate response to initial/induction therapy with a TNF-α inhibitor
  • Secondary loss of response, involving loss of initial response to a TNF-α inhibitor, which can be due to immune-mediated neutralising anti-drug antibodies
Up to one-fifth of patients receiving anti-TNF agents may not respond initially, and an additional 10%–15% may lose response every year despite an initial benefit

– Rubin et al., 20195

After failure of an initial TNF-α inhibitor, options include increasing the dose, shortening the dosing interval, switching to an alternative TNF-α inhibitor, or switching to a different class3. Decisions around which route to take may be informed by clinical context, plus measurement of serum drug concentrations (therapeutic drug monitoring) and anti-drug antibody concentrations3. Therapeutic drug monitoring can be used to evaluate reasons for loss of response, to inform whether to optimise the existing therapy or select an alternative therapy, particularly in moderate-to-severe UC5. However, European guidelines note there is insufficient evidence to recommend for or against the use of therapeutic drug monitoring to improve clinical outcomes1.

Indications for treatment switching after failure of TNF- α inhibitors are summarised in Table 2.

Table 2. Suggested indications for treatment switching after failure of TNF-α inhibitors in ulcerative colitis3,5,11. *Optimal drug levels for infliximab and adalimumab have not been defined, and depend on the assay used and clinical context3. TNF-α, tumour necrosis factor alpha.

Type of TNF-α inhibitor treatment failure Suggestions for treatment switching
Primary non-response
Defined as an inadequate response to initial/induction therapy with a TNF-α inhibitor		 Switching to a drug with a different mechanism of action is more likely to be successful than obtaining response to a second TNF-α inhibitor, particularly if the serum drug concentration is adequate
Secondary loss of response
Defined as a loss of initial response to a TNF-α inhibitor; may be due to immune-mediated neutralising anti-drug antibodies		 Appropriate changes to treatment can be informed by measuring:
• Serum drug concentration (therapeutic drug monitoring)
• Anti-drug antibody concentrations

Within-class switch (to another TNF-α inhibitor):
• Consider if active disease, low drug levels and high levels of anti-drug antibodies, particularly if the patient was responsive to treatment over a prolonged period
• Consider combining with immunomodulator therapy, to reduce risk of future antibody-mediated loss of response

Out-of-class switch (treatment with a different mechanism of action):
• If active disease despite optimal* drug levels
• If active disease with sub-optimal drug level
   and high levels of anti-drug antibodies

Indications for surgery in UC

The main indications for surgery in people with UC are acute severe UC (ASUC) and treatment-refractory UC34  

According to guidelines, surgery should be considered for people with:

  • Chronic treatment-refractory UC5,35, including those refractory to induction of remission with biologics, corticosteroids or small molecule treatments, and in cases of corticosteroid dependency5
  • Fulminant colitis, toxic megacolon or colonic perforation35
  • ASUC who are hospitalised and refractory to treatment, noting urgent surgery is indicated for those with toxic megacolon (<5% of people with ASUC), colonic perforation, severe refractory/massive haemorrhage or multi-organ dysfunction5
  • Neoplasia of the colon or rectum35

Early surgical consultation is also recommended for hospitalised people with moderate-to-severe UC who are undergoing escalation of medical treatment, to guide optimal care35.

Delayed surgery in people with ASUC is associated with poor outcomes and an increased risk of surgical and post-operative complications3,5

Successful surgical intervention may provide resolution for ongoing UC symptoms, remove the need for ongoing continuous medical care and immunosuppressive treatments, and protect the patient from risk of malignancy34. However, it is important to consider which surgical strategy is most appropriate to ensure that long-term functional outcomes are acceptable to the patient, and to help minimise peri-operative complications34.

Shared decision-making and collaborative care in UC

Benefits of shared decision-making in UC

With the availability of a growing number of medications for the management of ulcerative colitis (UC), treatment decision-making has become increasingly complex10.

People with inflammatory bowel disease (IBD) value being actively involved in decisions about their care36, and shared-decision making is considered an ideal model for involving them in individual treatment decision-making37. This involves working with patients to consider the available management strategies, their associated benefits, risks and uncertainties, as well as patient preferences and goals37. These decision-making conversations can be facilitated by web-based and decision-aid tools, particularly early in the disease course10.

Overall, shared decision-making can help clinicians to align treatment decisions with the person’s needs and preferences. This facilitates appropriate individualised treatment decisions, improving treatment adherence and compliance, and thereby improving overall patient health outcomes37.

Evidence has demonstrated a shared decision-making approach can improve satisfaction and adherence with treatment, and improve outcomes for people with IBD38

Key components for optimal shared decision-making in UC are provided in Figure 4.

Figure 4. Optimal shared decision-making in ulcerative colitis8,37-39. QoL, quality of life.

Figure 4. Optimal shared decision-making in ulcerative colitis8,37-39. QoL, quality of life.

Involving patients in shared decision-making

As part of shared decision-making, evidence suggests people with IBD value the ability to go beyond the focus on their gastrointestinal symptoms, to encompass other symptoms and adverse effects that can significantly reduce their quality of life37.

The way treatment options are framed in discussion with patients can significantly impact patients’ treatment decisions. The framing of treatment options such as surgery as a last resort, rather than one of several treatment options, may limit treatment decision-making, possibly even delaying appropriate and effective treatment10.

To enable people with UC to make informed decisions about their healthcare, it is important to accurately communicate and discuss the risks and benefits of available treatment options38.

While some people with IBD may be willing to tolerate an increased risk of adverse effects if a medication is highly efficacious and likely to achieve remission, others may not40

Ensuring people with UC are aware of the need for consistent, vigilant treatment because of the chronic nature of their disease can assist with long-term adherence to treatment10.

It can also be helpful to discuss the patient’s psychological burden, including social stigma and isolation, associated with their UC. Discussing these issues and considering their impact on decision-making may help to optimise treatment decisions and improve patient outcomes10.

Coordinated care and patient support in UC

A multidisciplinary approach to UC management

A multidisciplinary approach is recommended to facilitate optimised and personalised care of people with UC1,3. Alongside the gastroenterologist and primary care provider, multidisciplinary teams (MDTs) may include a colorectal surgeon, specialist nursing support, radiologist, dietitian, histopathologist and a pharmacist with expertise in IBD1,3. Referral to appropriate psychological support may also be required1,36. MDTs benefit from having a designated coordinator to assist with obtaining advice from these and other specialist disciplines, where necessary3.

People with UC can also benefit from surgical input at an earlier stage, so it can be discussed alongside other treatment options and help patients to understand it is “not an outcome to be avoided at all costs”3.

Once the patient has achieved remission and is on stable treatment, their primary care provider may manage the prescribing and monitoring of treatments, and encourage treatment adherence3. As primary care is usually the first point of contact for people who have deteriorating symptoms of UC, clear and comprehensive communication between the primary care provider and the hospital is an important consideration3.

Providing resources and support for people with UC

In addition to education provided by healthcare professionals, people with UC can benefit from access to educational materials on their disease and treatment options, reliable online resources and patient support groups41. Peer support groups or programmes can provide opportunities to connect with those who have lived experience with UC41, and have the potential to empower patients to learn coping strategies and acquire self-management skills42.

References

  1. Raine, 2022. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment. <link: https://www.doi.org/10.1093/ecco-jcc/jjab178 >
  2. Burri, 2020. Treatment Algorithm for Mild and Moderate-to-Severe Ulcerative Colitis: An Update. <link: https://www.doi.org/10.1159/000504092 >
  3. Lamb, 2019. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. <link: https://www.doi.org/10.1136/gutjnl-2019-318484 >
  4. Burisch, 2023. Lack of Benefit for Early Escalation to Advanced Therapies in Ulcerative Colitis: Critical Appraisal of Current Evidence. <link: https://www.doi.org/10.1093/ecco-jcc/jjad106 >
  5. Rubin, 2019. ACG Clinical Guideline: Ulcerative Colitis in Adults. <link: https://www.doi.org/10.14309/ajg.0000000000000152 >
  6. Wetwittayakhlang, 2021. Treatment Targets in Ulcerative Colitis: Is It Time for All In, including Histology? <link: https://www.doi.org/10.3390/jcm10235551 >
  7. Harbord, 2017. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: Current Management. <link: https://www.doi.org/10.1093/ecco-jcc/jjx009 >
  8. Ferretti, 2022. An Update on Current Pharmacotherapeutic Options for the Treatment of Ulcerative Colitis. <link: https://www.doi.org/10.3390/jcm11092302 >
  9. Ko, 2019. AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis. <link: https://www.doi.org/10.1053/j.gastro.2018.12.009 >
  10. Lai, 2019. Patient decision-making in severe inflammatory bowel disease: the need for improved communication of treatment options and preferences. <link: https://www.doi.org/10.1111/codi.14759 >
  11. Feuerstein, 2020. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis. <link: https://www.doi.org/10.1053/j.gastro.2020.01.006 >
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  13. Torres, 2023. European Crohn's and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation. <link: https://www.doi.org/10.1093/ecco-jcc/jjac115 >
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  18. Entyvio (vedolizumab) highlights of prescribing information, 2022. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/125476Orig1s046lbl.pdf
  19. Xeljanz (tofacitinib) highlights of prescribing information, 2022. https://labeling.pfizer.com/showlabeling.aspx?id=959
  20. Zeposia (ozanimod) highlights of prescribing information, 2022. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/209899s005lbl.pdf
  21. Stelara (ustekinumab) summary of product characteristics, 2022. https://www.ema.europa.eu/documents/product-information/stelara-epar-product-information_en.pdf
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  23. Remicade (infliximab) summary of product characteristics, 2022. https://www.ema.europa.eu/documents/product-information/remicade-epar-product-information_en.pdf
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  29. Entyvio (vedolizumab) summary of product characteristics, 2023. https://www.ema.europa.eu/documents/product-information/entyvio-epar-product-information_en.pdf
  30. Rinvoq (upadacitinib) summary of product characteristics, 2023. https://www.ema.europa.eu/documents/product-information/rinvoq-epar-product-information_en.pdf
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  32. Jyseleca (filgotinib) summary of product characteristics, 2023. https://www.ema.europa.eu/documents/product-information/jyseleca-epar-product-information_en.pdf
  33. Xeljanz (tofacitinib) summary of product characteristics, 2023. https://www.ema.europa.eu/documents/product-information/xeljanz-epar-product-information_en.pdf
  34. Spinelli, 2022. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment. <link: https://www.doi.org/10.1093/ecco-jcc/jjab177 >
  35. Holubar, 2021. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis. <link: https://www.doi.org/10.1097/DCR.0000000000002037 >
  36. Karimi, 2023. Health Communication Research Informs Inflammatory Bowel Disease Practice and Research: A Narrative Review. <link: https://www.doi.org/10.1093/crocol/otad021 >
  37. Schoefs, 2023. What are the Unmet Needs and Most Relevant Treatment Outcomes According to Patients with Inflammatory Bowel Disease? A Qualitative Patient Preference Study. <link: https://www.doi.org/10.1093/ecco-jcc/jjac145 >
  38. Wei, 2021. Epidemiology, burden of disease, and unmet needs in the treatment of ulcerative colitis in Asia. <link: https://www.doi.org/10.1080/17474124.2021.1840976 >
  39. Armuzzi and Liguori, 2021. Quality of life in patients with moderate to severe ulcerative colitis and the impact of treatment: A narrative review. <link: https://www.doi.org/10.1016/j.dld.2021.03.002 >
  40. Bewtra and Johnson, 2013. Assessing patient preferences for treatment options and process of care in inflammatory bowel disease: a critical review of quantitative data. <link: https://www.doi.org/10.1007/s40271-013-0031-2 >
  41. McDermott, 2018. Patient Education in Inflammatory Bowel Disease: A Patient-Centred, Mixed Methodology Study. <link: https://www.doi.org/10.1093/ecco-jcc/jjx175 >
  42. Adriano, 2022. Peer support for carers and patients with inflammatory bowel disease: a systematic review. <link: https://www.doi.org/10.1186/s13643-022-02064-6 >
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