Edward Loftus, MD, on Recognizing and Managing Smoldering Ulcerative Colitis

Edward V. Loftus, Jr, MD, highlighted the challenges of managing “smoldering” ulcerative colitis (UC), underscoring the risks associated with untreated histologic inflammation, even in the absence of overt symptoms, in his presentation at the 2025 AIBD annual meeting.

Dr Loftus is the Maxine and Jack Zarrow Family Professor of Gastroenterology Specifically in IBD at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota.

“There can be a disconnect between rectal bleeding or stool frequency and endoscopic or histologic activity,” Dr Loftus explained. Patients may appear clinically well but still harbor persistent inflammation that contributes to long-term complications.

This subclinical inflammation, if left unaddressed, has meaningful clinical consequences. According to Dr Loftus, “Uncontrolled inflammation leads to increased risks of hospitalization, colectomy, and dysplasia or cancer.” He also emphasized that many patients with endoscopic remission still report abnormal stool frequency, sometimes attributed to overlapping irritable bowel syndrome (IBS), but may instead reflect ongoing intestinal dysfunction such as increased permeability or altered motility.

While UC is traditionally considered a superficial mucosal disease, Dr Loftus noted that evidence points to deeper changes over time. These include proximal disease progression, fibrosis, and even damage to the enteric nervous system. Up to 11% of patients may develop strictures. “Think of the 'ahaustral' or 'tubular colon,’” he said, referencing the structural changes observed in chronic disease.

Despite the ease of prescribing corticosteroids, Dr Loftus urged caution due to the cumulative toxicity associated with their use. A standard tapering regimen can result in a total dose of over 1500 mg. “A cumulative dose of greater than 1000 mg was associated with a 60% increased risk of hip fracture,” he said, citing a population-based Danish study. Additional risks include serious infections, cataracts, glaucoma, hyperglycemia, hypertension, and osteonecrosis.

Instead, he advocated for treatment plans aimed at eliminating inflammation entirely—not just symptom control. This requires objective monitoring and a willingness to escalate therapy when histologic activity persists. “The bottom line: Treat smoldering inflammation,” Dr Loftus concluded.

His message to gastroenterologists was clear—clinical remission is not enough. Ongoing inflammation, even in the absence of symptoms, demands proactive, long-term management to prevent irreversible bowel damage and poor outcomes.

Reference
Loftus E. The patient with smoldering ulcerative colitis. Presented at: 2025 AIBD Annual Meeting. December 8-10, 2025.