The management of ulcerative colitis (UC) has undergone a fundamental transformation over the past two decades, driven by a deeper understanding of disease progression and an expanding armamentarium of advanced therapies. In this interview, Benjamin Cohen, MD, Co-Section Head and Clinical Director of Inflammatory Bowel Diseases in the Department of Gastroenterology, Hepatology, and Nutrition at the Cleveland Clinic, sat down to discuss how UC treatment paradigms have evolved, recent updates to management and treatment, and what clinicians should prioritize in contemporary practice.

A Shift Toward Earlier Use of Effective Therapies

One of the most significant changes in UC management has been the move away from a traditional step‑up approach toward earlier use of highly effective therapies in appropriate patients. Historically, clinicians initiated treatment with less potent, non‑immunosuppressive medications and escalated only after disease progression or treatment failure. According to Dr. Cohen, this approach no longer reflects current evidence.

“Over my career, the biggest change I've seen in management of ulcerative colitis is the heightened importance of treating disease early with our most effective therapies,” he explained. Research over the past 15 to 20 years has clarified that UC is not a static condition but rather one that can progress over time if inflammation is not adequately controlled. “Ulcerative colitis is a progressive disease, and the earlier we control inflammation, the better long‑term outcomes will be.”

This shift reframes early disease as a critical therapeutic window. Dr. Cohen emphasized that intervening early can help prevent cumulative bowel damage and reduce the risk of future complications. “Early disease is a window of opportunity to control disease and prevent long‑term complications, including the need for surgery,” he noted.

Identifying Patients at Risk for Severe Disease

Timely identification of patients at risk for a more aggressive disease course is essential to leveraging this window of opportunity. Dr. Cohen highlighted that uncontrolled inflammation can lead to disease extension and serious systemic consequences.

“Early disease is a window of opportunity to control inflammation before progression of disease, including extension to pancolitis, severe flare requiring hospitalization and development of blood clots, among other complications,” he said. Recognizing “red flag features for a severe disease course” allows clinicians to initiate advanced therapies sooner and potentially alter the disease trajectory.

For the multidisciplinary care team—including physicians, nurses, and pharmacists—this underscores the importance of vigilant monitoring, prompt evaluation of disease activity, and readiness to escalate therapy when risk factors emerge.

Guideline Updates and a Rapidly Evolving Landscape

UC treatment continues to evolve rapidly, with ongoing updates to clinical guidance. Dr. Cohen pointed to recent changes in professional society recommendations as a valuable resource for clinicians navigating therapeutic complexity.

“Updates in the last year include updates to both the American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) guidelines on management of moderate-to-severe ulcerative colitis,” he said. These updates provide direction on the positioning of advanced therapies for both treatment‑naive patients and those previously exposed to biologics or other advanced agents.

Staying current, however, requires intentional effort. “Management of UC is a rapidly evolving landscape, and it's important to keep up to date with the available treatment options and positioning recommendations as we continue to learn more,” Dr. Cohen noted. He described relying on the AGA Living Guidelines, national scientific meetings, and continuing medical education (CME) activities to remain informed, emphasizing that innovative educational formats can enhance engagement.

The Central Role of Shared Decision Making

As therapeutic options have expanded, shared decision making has become increasingly central to UC care. Early in the biologic era, discussions often focused narrowly on safety concerns related to immunosuppression. Today, with multiple effective agents available, treatment selection requires a more nuanced, individualized approach.

“Shared decision making can be important to help decide which one will fit the patient's disease and life,” Dr. Cohen said. He emphasized that therapies differ in safety profiles, routes of administration, and effectiveness in specific clinical contexts, such as severe disease or extraintestinal manifestations.

Establishing clear treatment goals with patients is critical. “Setting goals for treatment with the patient is critically important in helping to select the right therapy for them,” he explained. This collaborative approach supports adherence, aligns expectations, and enables the care team to tailor therapy to both clinical and lifestyle considerations.

Looking Ahead

Dr. Cohen anticipates continued progress in UC treatment, including new mechanisms of action and potentially novel combination strategies. As the field advances, he stressed the importance of ongoing education to ensure clinicians are equipped to deliver optimal care. “Staying on top of the rapidly evolving treatment landscape for UC is important for our patients,” he said.

Key Takeaways

Ulcerative colitis is a progressive disease, and “the earlier we control inflammation, the better long‑term outcomes will be.”
Early intervention matters: “Early disease is a window of opportunity to control disease and prevent long‑term complications, including the need for surgery.”
Rapid identification of high‑risk patients can help prevent progression to pancolitis, hospitalization, and systemic complications.
Updated ACG and AGA guidelines provide important guidance on positioning advanced therapies in moderate-to-severe UC.
Shared decision making is essential in an era of multiple advanced treatment options; aligning therapy with patient goals improves individualized care.

About Dr. Cohen

Benjamin Cohen, MD, MAS, AGAF, FCCF, is the Co-Section Head and Clinical Director for Inflammatory Bowel Diseases (IBD) in the Department of Gastroenterology, Hepatology, and Nutrition at the Cleveland Clinic. He specializes in clinical research for IBD, including ulcerative colitis, and he has been a site primary investigator for phase 3 clinical trials and collaborative investigator-initiated studies. Dr. Cohen is passionate about IBD education and served on the Education and Training Committee and the Clinical Guidelines Committee of the American Gastroenterological Association.

Additional Advances in Ulcerative Colitis Research and Clinical Trials With Benjamin Cohen, MD, MAS, AGAF, FCCF