A patient with inflammatory bowel disease reporting that things are 'not great' is describing something, and it is often not inflammation. Bile acid diarrhoea after ileal resection, small intestinal bacterial overgrowth, post-inflammatory gut-brain symptoms and simple lactose intolerance all produce a picture the patient reads as a flare, and all of them are treated differently from one.
So before escalating a biologic, get an objective measure alongside the symptom: faecal calprotectin, and where available a recent endoscopic or imaging assessment. The question is not whether the patient feels unwell — they do — but whether the inflammation and the symptom are moving together. When calprotectin is normal and the symptoms are real, the answer is a different diagnosis rather than a higher dose.
This also protects the drug. Escalating on symptoms alone attributes a failure to a treatment that was working, and once a biologic is recorded as failed it is rarely revisited.
- Check faecal calprotectin before escalating therapy on symptoms alone
- Consider bile acid diarrhoea in anyone with previous ileal resection
- Ask about lactose and about symptom timing relative to meals
- Record why a biologic was stopped, so a symptom-driven switch is not later read as true failure
Why it matters
A drug recorded as failed on symptoms alone is rarely tried again.
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