Patient Education Exchange: How Doctors Know When It's Time to Switch IBD Medications

This interview is the second installment of a two-part conversation with Mazyar Malakouti, M.D., for the Patient Education Exchange, a series that will spotlight different disease states; this installment focuses on inflammatory bowel disease (IBD).

Deciding whether a biologic is truly effective requires more than just asking how a patient feels, according to Malakouti, a gastroenterologist with GI Alliance and Texas Digestive Disease Consultants and an assistant professor at Texas Christian University. Malakouti said he uses fecal calprotectin, an inflammatory marker in the stool, to correlate with endoscopic findings at diagnosis. If a patient reports still feeling unwell but their calprotectin level has dropped, Malakouti said that suggests the treatment is working, just more slowly than hoped, and he's less inclined to rush toward switching medications. Conversely, if a patient reports feeling well but their calprotectin is rising, that may signal a need to change course. He generally allows three to six months before considering a therapy change if a patient isn't improving.

Malakouti said the goal is always to intervene early enough to prevent hospitalization or more serious complications, including surgery. "I don't want my patient to end up in a hospital with a complication of the disease," he said.

Communication as a Foundation for Care

Malakouti emphasized that patients should never hesitate to share symptoms or concerns, no matter how minor they may seem. "There are no stupid questions," he said, noting that small adjustments to a treatment plan can sometimes prevent a hospitalization or complication down the line. He described IBD management as a long-term, shared decision-making process built on trust, and said that if a patient doesn't feel that trust with their provider, finding a different provider is a reasonable step.

He also stressed the importance of patients knowing exactly how to reach their care team when problems arise, whether it's a portal message or a phone call, and receiving a timely response, ideally within 24 hours, since delays can matter significantly during a flare. Malakouti noted that some practices offer chronic care management programs that check in with patients regularly, which he considers highly beneficial, though not universally available.

Addressing the Mental Health Side of IBD

Malakouti said mental health remains an underaddressed aspect of IBD care, despite its clear connection to healing. He described actively asking patients how they're coping and referring those under significant stress to psychologists specializing in cognitive behavioral therapy. He also pointed patients toward resources like the Crohn's & Colitis Foundation and peer support groups, encouraging patients to connect with others managing similar disease.

A Message of Hope

Malakouti said his overarching goal is helping patients achieve a normal life, one where they can attend college, maintain friendships and pursue their goals despite an IBD diagnosis. While outcomes aren't guaranteed for every patient, he said the advancement of biologic therapy has meaningfully opened the door to that possibility, with more treatment options continuing to emerge. His message to patients: "There is hope for you. Get the help that you need and have a normal life."