Editorial: Remission Ambition—How Far Should We Push in Older Adults? Authors' Reply

We thank Drs. Lin and Boland for their thoughtful insights and interest in our recent work. As they noted, while the STRIDE-II guidelines support targeting clinical and endoscopic remission across all adults, the application of these goals in older adults with mild ongoing endoscopic inflammation is less clear [1, 2]. Given the shorter time horizon for developing inflammation-related complications such as surgery or dysplasia, the magnitude of benefit from a change in therapy may be more limited in the near term. Moreover, as older adults face higher risks of treatment-related adverse events, decisions to escalate or switch therapy must be carefully weighed in this broader clinical context. To further assess this question, we examined both IBD-specific outcomes and comorbidity-related events at 1-year and 5-year horizons, comparing older adults who achieved endoscopic remission to those with mild ongoing endoscopic disease [3]. We found a decreased risk of IBD-related outcomes associated with endoscopic remission, which persisted through 5 years of follow-up and held true for both Crohn's disease and ulcerative colitis. When evaluating IBD-specific outcomes, we found that within just 1 year, the proportion of individuals requiring corticosteroids for IBD flares was nearly six-fold higher among those with persistent mild endoscopic activity (12.5% vs. 2.2%). This is particularly important, as corticosteroid use in older adults is associated with substantial risks including infection, osteoporosis and mortality [4, 5]. Our study also began to address whether there are broader benefits to achieving endoscopic remission beyond IBD-focused measures. Mild endoscopic disease activity was associated with a 50% higher risk of morbidity-related adverse outcomes, including mortality, all-cause hospitalisation, cardiovascular events, venous thromboembolism, infections requiring antibiotics, and osteoporotic fractures within 1 year. This suggests that even modest ongoing inflammation may contribute to systemic complications in this vulnerable patient population. Taken together, these findings challenge current paradigms that contribute to the undertreatment of older adults with IBD and highlight that even mild, ongoing inflammation can have meaningful and immediate clinical consequences in this population. As we continue to refine therapeutic targets for older adults with IBD, these results can help guide future efforts to identify which patients derive the greatest benefit from tighter disease control, while ensuring that treatment decisions remain individualised and informed by overall health status, prior treatment history and personal goals of care. Catherine Z. Tang: writing – original draft. Adam S. Faye: writing – original draft. The authors have nothing to report. The authors' declarations of personal and financial interests are unchanged from those in the original article [3]. This article is linked to Tang et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70414 and https://doi.org/10.1111/apt.70463. The authors have nothing to report.