Patient Education Exchange: Starting Biologic Therapy for IBD

This interview is part of the Patient Education Exchange, a series that will spotlight different disease states; this installment focuses on inflammatory bowel disease (IBD).

The approach to treating IBD has evolved significantly, according to Mazyar Malakouti, M.D., a gastroenterologist with GI Alliance and Texas Digestive Disease Consultants and an assistant professor at Texas Christian University. Malakouti said research increasingly supports starting biologic, or advanced, therapy earlier rather than waiting, since ongoing inflammation left untreated can lead to complications down the line.

Once a diagnosis of Crohn's disease or ulcerative colitis is confirmed through scopes, stool studies, imaging and patient history, Malakouti said the conversation shifts to matching a patient with the right therapy. That decision depends on several factors working together: the extent and severity of disease; whether a patient prefers a daily pill, injection or infusion; and considerations such as childbearing status, since some medications aren't safe during pregnancy. He also factors in whether a patient has symptoms beyond the gut, such as skin or joint involvement, and selects an agent that can address multiple symptoms when possible.

Above all, Malakouti said access is often the deciding factor. "The best medicine is the one that I can get to the patient the fastest," he said, since even an ideal treatment plan falls apart if a patient can't actually obtain the medication.

Navigating Insurance and Access

Malakouti described the process that follows a prescription: Insurance companies frequently reject initial requests, prompting a prior authorization and letter of medical necessity. If that's also denied, many pharmaceutical companies offer patient assistance programs that can provide the medication at low or no cost until insurance coverage is finalized. He noted that some companies are especially efficient at getting a first dose to patients quickly, sometimes within a day, through samples or assistance programs, which matters for patients who are acutely ill and can't wait weeks for treatment to begin.

Malakouti also addressed common patient concerns about biologics, particularly fears around infection risk or malignancy. He said it's important to weigh those concerns against the risks of uncontrolled disease and long-term steroid use, which carries its own significant safety concerns. He explained that biologics target specific inflammatory pathways rather than suppressing the immune system broadly, with some agents being highly gut-selective.

Setting Realistic Expectations

Patients typically begin noticing improvement within two to three weeks of starting a biologic, though for medications dosed every four weeks, that timeline can extend closer to the third or fourth week before the next dose. Malakouti said some patients respond more slowly and cautioned against switching therapies too quickly. "It is important to be patient and give it enough time," he said, noting that as patients complete their loading doses, symptoms typically continue to improve. He emphasized the value of setting expectations up front so patients understand what their treatment course will likely look like from the start.