Inflammatory bowel disease (IBD) encompasses a group of chronic disorders including Crohn’s disease (CD) and ulcerative colitis (UC), characterised by persistent and relapsing inflammation of the gastrointestinal tract. These conditions not only have a negative impact on patients’ quality of life, but are also associated with long-term complications that may lead to disability.1,2 As IBD most often begins during adolescence or early adulthood, frailty constitutes a critical yet frequently underestimated aspect of the disease. Frailty is a condition characterised by reduced physiological reserve and diminished resilience to stressors, resulting in greater vulnerability and an increased risk of adverse outcomes. Frailty is a condition characterised by reduced physiological reserve and diminished resilience to stressors, resulting in greater vulnerability and an increased risk of adverse outcomes. It involves not only physical aspects, but also psychological and social dimensions.3 The rising prevalence of IBD, coupled with a mortality rate very similar to that of the general population, makes it increasingly urgent to understand and address frailty in these patients. The interaction of chronic inflammation, malnutrition, loss of muscle mass and other factors exacerbates frailty and, consequently, the risk of hospitalisation, surgical complications and mortality.4

Identifying and managing frailty in IBD is a clinical challenge and requires a multidimensional approach. This position paper aims to show the interrelationship between frailty and IBD, its prevalence, the main risk factors, its clinical implications in IBD and reviews available tools for its identification and potential intervention strategies.

According to the dictionary of the Royal Spanish Academy, fragile means "that which may deteriorate easily".5 In health terms, the most widely accepted definition among the many in existence is that developed in the field of geriatrics, which defines frailty as a biological syndrome of reduced reserve and resistance to stressors, resulting from the cumulative decline of multiple physiological systems, conferring increased vulnerability and risk of adverse outcomes.6,7 With ageing, a gradual decline in physiological reserve occurs; in frailty, this decline is accelerated and homeostatic mechanisms begin to fail.8 A frail person has a higher risk of disability and mortality following even minimal external stressors.

Frailty becomes more prevalent with ageing, although not all older people are frail.9 Conversely, frailty can occur at any age, particularly in individuals with chronic disease.8 The risk of frailty increases with chronological age, the presence of comorbidities, cognitive decline, sensory impairment (hearing and vision), polypharmacy, low physical activity, poor dietary intake, and low socioeconomic status, among other factors (Table 1).10 One critical factor that has received special attention in recent years is sarcopenia (loss of muscle mass), which leads to weakness and impaired muscle function, and is frequently associated with ageing.11

Although often mistakenly used as synonyms in clinical practice, frailty, disability and comorbidity are distinct concepts. Comorbidity, defined as the coexistence of multiple diseases and medical conditions in the same individual, may contribute to the onset and progression of frailty (and vice versa). Disability is determined by any limitation or restriction in an individual’s activity or social participation due to a health condition. Frailty, however, may represent a precursor stage to disability and should be considered a dynamic process, as its severity may fluctuate and can even be reversible.12

Assessment of frailty makes it possible to distinguish between robust, pre-frail, frail, and disabled individuals. The prevalence of frailty in the population is often difficult to establish, because the available data are heterogeneous, both in terms of the methods used for assessment and the populations studied.11 The overall prevalence of frailty in Europe has been estimated at 18%, ranging from 12% in community-dwelling individuals to 45% in other settings. This variation reflects fluctuations in frailty during acute illness and the high level of chronic multimorbidity among institutionalised patients.13

Frailty is associated with a greater risk of adverse health outcomes, including falls, hospitalisation, institutionalisation, and mortality, as well as an exponential increase in healthcare costs.7 Although there is broad consensus regarding the theoretical concept of frailty, the complexity of its pathophysiology and the diversity of predisposing factors make it difficult to establish universal diagnostic criteria and a gold standard for its assessment10,11 (Fig. 1).

Figure 1.

Factors associated with the development of frailty.

The detection and appropriate management of frailty lead to significant improvements in health outcomes for patients, potentially increasing independence and reducing the burden on caregivers and healthcare systems. Comprehensive geriatric assessment (CGA) is the reference tool for evaluating frailty.

CGA is a multidimensional diagnostic process, usually interdisciplinary, aimed at quantifying an individual’s medical, functional, psychological and social problems and capabilities, and enabling the design of a treatment and follow-up plan. Although it requires time and specialised training, CGA performed by a multidisciplinary team with expertise in geriatrics has been shown to improve health outcomes compared with the traditional medical approach.14

As it is not feasible to carry out a CGA for all older adults, frailty screening enables the detection of those at high risk who should be referred for a full CGA. The most widely known and used methods for screening and evaluating frailty in older adults are the Fried phenotype7 and frailty indices, both of which provide crucial information about frailty status and have particular advantages depending on the evaluation context.15,16

The Fried phenotype defines frailty as a clinical syndrome with specific criteria, based on the presence of five physical characteristics.7 A person is considered frail if three or more of the following criteria are met:

• 1

  Unintentional weight loss: specifically, loss of more than 4.5 kg or 5% of body weight in the past year.

• 2

  Muscle weakness: measured by handgrip strength, adjusted for sex and body mass. Frailty is defined when strength falls within the lowest quintile.

• 3

  Slowness in the lowest quintile indicates frailty. Slowness in the lowest quintile indicates frailty.

• 4

  Self-reported fatigue or exhaustion: individuals report a persistent sensation of tiredness or exhaustion.

• 5

  Low physical activity: measured by weekly energy expenditure in physical activities; as with the other parameters, being in the lowest quintile according to sex indicates frailty.

The Fried phenotype is useful because it identifies individuals at an early stage who are at higher risk of adverse health outcomes, such as disability, hospitalisation, falls and mortality.7

Mathematical frailty indices, also known as deficit accumulation models, provide a different perspective for evaluating and quantifying frailty in older people. This approach, popularised by Rockwood and Mitnitski,17 measures frailty as an index that summarises the number of health problems or deficits a person has accumulated.

One of the most widely used and evidence-based indices is the Frail-CGA Index (IF-VIG). This tool was specifically designed to identify and classify the degree of frailty in older adults. It encompasses different domains, including functional, nutritional, cognitive, emotional and social aspects, as well as geriatric syndromes, severe symptoms and chronic diseases. The FI-VIG stands out for its practicality and efficiency, allowing a rapid assessment of frailty through 22 questions covering 25 deficits. These range from difficulties with instrumental activities of daily living (such as managing money or medication) to specific clinical conditions (such as malnutrition, cognitive impairment, depression, insomnia or social vulnerability). It also considers the presence of geriatric syndromes, such as falls or pressure ulcers, polypharmacy, and chronic diseases affecting different organs or systems. The IF-VIG provides a score that reflects the degree of frailty and complements the Fried phenotype. While the Fried phenotype identifies frailty on the basis of specific physical features, the FI-VIG offers a broader and more detailed perspective incorporating clinical, functional and social aspects, thus enabling a more comprehensive assessment of an individual’s condition. The IF-VIG is particularly useful in clinical settings where rapid and efficient frailty screening is required to support decision-making.18 A publicly accessible calculator is available via the website of the Chronicity Research Group of Central Catalonia (C3RG): https://es.c3rg.com/index-fragil-vig.

The Clinical Frailty Scale (CFS) is another tool developed to assess frailty in older adults, originally designed by Rockwood et al.19 Unlike the IF-VIG, the CFS provides a qualitative and more visual measure of frailty using a simple visual scale based on clinical observation and judgement (Fig. 2). It classifies frailty into nine categories, each illustrated with images and detailed descriptions of activity level, independence, and health status. The CFS is widely used in clinical settings to quickly evaluate frailty, which is especially helpful in acute care situations for supporting clinical decisions. Its intuitive format makes it easy to use by healthcare professionals without the need for extensive training. However, the CFS may be subjective, depending on the assessor’s interpretation, and may not detect subtle changes in frailty status. The CFS is also available as a mobile application: https://www.scfn.org.uk/cfs-app.20

Figure 2.

Clinical frailty scale.

The most recent population-based studies have reported an increase in the incidence of IBD in developing countries and a rising global prevalence, with the highest rates observed in North America and Europe (prevalence 0.3%).21,22 This phenomenon is likely multifactorial, with contributing factors including exposure to environmental influences such as a Western diet and pollution,23 as well as the global increase in life expectancy.24

Approximately 25–30% of patients with IBD are over 60 years old, a proportion expected to increase further given population ageing and the rising incidence of IBD in this age group.25–30 Several studies have shown that the incidence of IBD among individuals aged >60 years accounts for 10–20% of incident cases, making this the subgroup with the sharpest increase over recent decades. Unlike in younger populations, incidence rates do not decline with age, particularly in regions with a high socioeconomic status.27,31–40 In addition, improvements in diagnostic techniques and greater awareness of IBD may have reduced the rate of undiagnosed cases in this population.23

In clinical practice, two distinct subgroups of older patients with IBD can be identified: those diagnosed at a younger age and ageing with long-standing disease, and those diagnosed at an older age (referred to as late-onset IBD). Although all patients diagnosed over the age of 40 fall into the A3 group of the Montreal classification (for CD), it is recognised that late-onset IBD presents with distinct phenotypic features, including a more indolent course and a higher risk of drug-related toxicity.23,24

Some studies indicate a higher proportion of UC compared with CD among older patients (ratio 4:1.5).36,39 Compared with IBD diagnosed earlier in adulthood, late-onset disease tends to show a predominance of colonic location, a lower tendency towards penetrating disease, reduced rates of perianal involvement in CD, and a predominance of distal disease in UC.39,41–43 These differential characteristics are summarised in Table 2.

A systematic review comparing the course of IBD in patients diagnosed at <60 years versus >60 years found similar rates of corticosteroid use. However, the use of immunosuppressants and biologics was lower in older patients.43 Although a milder disease course has traditionally been described in this population, rates of surgery and hospitalisation tend to be higher. This, together with the lower use of advanced therapies, may reflect a more conservative therapeutic approach.

Older patients with IBD show higher rates of comorbidity and polypharmacy, and therefore at increased risk of adverse events. In addition, patients with IBD develop geriatric syndromes, such as osteoporosis, hip fractures, infections and malignancies, and have an increased risk of cognitive and psychomotor disorders at younger ages44–49 (Fig. 3). Moreover, frailty has been observed at earlier ages in patients with IBD, probably related to the chronic inflammatory burden of the disease.50 However, the causal relationship between IBD and frailty remains debated. While some studies suggest a frail phenotype may predispose to the development of IBD,51 others have reported that IBD activity contributes to frailty and accelerates its onset.52

Figure 3.

Algorithm for the management of the frail patient with inflammatory bowel disease.

In a cohort of 11,001 patients with IBD across all ages, Kochar et al. reported that frailty prevalence increased with age, rising from 4% among patients aged 20–29 years to 25% among those aged >90 years.53 A recent meta-analysis, including nine studies with 1,495,695 patients, estimated frailty prevalence at approximately 18% in patients with IBD.54

Initial studies assessing frailty in IBD were conducted in surgical settings and demonstrated that frailer patients experienced higher morbidity and mortality and a greater likelihood of reintervention.55–57 The association between frailty and infection risk remains controversial: some studies report a higher risk of infections related to anti-TNF or immunosuppressive therapy,57 while others have found no increase in serious infections, or only an association with certain treatments such as vedolizumab.58 Frail patients with IBD have also been shown to have a higher risk of hospitalisation and reduced quality of life and functional status.57,59

A recent Italian prospective study suggested the only factor associated with frailty was IBD activity.60 The same group also showed that improvement in frailty phenotype correlated directly with the use of biologics and inversely with persistent clinical activity.52 This observation had previously been reported in a retrospective US study of 1210 patients with IBD initiating anti-TNF therapy,61 reinforcing the concept of frailty as a dynamic state influenced by IBD activity.

Managing IBD in older adults presents unique challenges. This population is more susceptible to drug-related adverse events, necessitating closer monitoring and careful risk–benefit assessment before treatment initiation.61 The pharmacokinetics and pharmacodynamics of medications may be altered in elderly patients due to physiological changes associated with ageing, so dose64 adjustment may be necessary, which could influence therapeutic efficacy. On the other hand, we have little data on the impact of frailty or comorbidities on the efficacy and safety of different drugs. in part because most clinical trials exclude patients with common comorbidities seen in older adults.65 These factors may lead to less ambitious treatment targets, which can, in turn, influence the trajectory of frailty and its consequences.

Nutrition in the frail patient with inflammatory bowel disease Nutrition in IBD patients is a crucial aspect of care, with particular nuances in those who are frail. The prevalence of malnutrition is higher in older adults and rises further in the presence of frailty due to the combination of multiple factors.122 Advanced age itself is associated with physiological changes in body composition as a consequence of ageing.123 In addition, comorbidities are common (diabetes, pulmonary, renal, hepatic, cardiovascular or cerebrovascular disease, and neurological disorders) and patients are often exposed to repeated hospital admissions. Other frequent contributing factors include loss of appetite or dietary modification due to difficulties with chewing.124,125 Neuropsychiatric conditions (depression, anxiety, cognitive decline)126 and social circumstances (loneliness, isolation, inability to shop or cook, and, at the extreme, dependency) may also contribute to weight loss and malnutrition, even in the absence of underlying organic disease. In frail or older patients with IBD, these factors are further compounded by the digestive disease itself, although individual scenarios vary widely depending on disease-related factors such as location, activity, and history of surgery. The interaction between inflammation, comorbidity and frailty largely determines the nutritional status. Correcting malnutrition in a frail patient can improve frailty—particularly its physical domain—and thereby indirectly minimise the risks of certain IBD therapies and optimise health outcomes.

The term sarcopenia derives from the Greek for “poverty of flesh” and was first coined in 1989 to describe muscle loss. Initially lacking a formal definition or diagnostic criteria, it has since been established as a distinct entity (ICD code M62).131,132 Sarcopenia is defined as a progressive and generalised disorder of skeletal muscle characterised by a marked reduction in muscle mass, accompanied by loss of strength and physical performance.

The prevalence of sarcopenia in IBD appears to be higher than in the general population. According to a recent systematic review, one third of adult IBD patients would have myopenia and presarcopenia and almost one fifth would have sarcopenia.133 In frail or older IBD patients, the prevalence is presumed to be even greater. In general, sarcopenia is associated with loss of autonomy, higher risk of falls and fractures, hospitalisation and even mortality, with the consequent increase in healthcare costs. Among frail patients or those with comorbidities, these negative consequences are magnified, increasing overall vulnerability.134,135 Importantly, sarcopenia has also been associated with higher relapse rates and lower remission rates in patients with IBD, irrespective of age or frailty.136,137 Other studies suggest that the risks or effectiveness of certain therapies, including immunomodulators and biologics, may be independently modified by the presence of sarcopenia.138 In addition, sarcopenia has been linked to increased postoperative complications. While the precise mechanisms remain unclear, it is noteworthy that skeletal muscle appears to play roles in inflammatory regulation and possibly in immune function.139

Comorbidity is defined as the presence of one or more additional diseases or disorders that coexist with a primary disease in the same patient, whether they are independent of the primary condition. Comorbidity can influence the clinical course, prognosis, and treatment of IBD. In older patients with IBD, the prevalence of comorbidities exceeds 13%,56 which may be related to ageing-associated inflammation.152,153 Moreover, multimorbidity is linked to greater complexity in clinical management, as well as reduced quality of life and life expectancy.

Regardless of age, comorbidities are often used as an exclusion criterion in clinical trials, leading to their under-representation and leaving an important gap in the available evidence.53,154 Indeed, in older patients with IBD, it is comorbidities—rather than age itself—that have been associated with delayed initiation of immunosuppressive treatments, particularly in CD.155

Patients with IBD and comorbidities are more likely to experience certain complications, such as thrombosis, compared with those without comorbidities.156 Several studies have shown an increased risk of cardiovascular disease in patients with IBD, alongside non-traditional risk factors compared with the general population, such as younger age, female sex, and disease activity.157,158 In this context, it has been observed that controlling inflammation with agents such as anti-TNFs may help reduce cardiovascular risk, over and above their direct immunological effect.159

In terms of metabolic disease, recent studies indicate patients with IBD are twice as likely to develop type 2 diabetes.160–163 Alterations in the gut microbiota have been hypothesised as a potential cause,161 although a causal correlation has not been firmly established. Changes in the gut microbiota can lead to alterations in local and systemic immunity, which in turn can contribute to systemic disorders such as obesity, atherosclerosis, or diabetes. Indeed, the prevalence of obesity among patients with IBD has increased in recent decades, with an estimated 15–40% of adult patients classified as obese, irrespective of IBD subtype.164,165

The risk of neoplasia is also higher in patients with IBD, independent of treatment.166 Several studies report that the IBD population faces an increased risk of malignancies due to chronic inflammation itself—as in the case of colorectal cancer and cholangiocarcinoma.117 Older age is an independent risk factor for many cancers associated with IBD and its treatment, particularly with thiopurines.84 Conversely, a more recent systematic review and meta-analysis167 showed that overall cancer risk in IBD patients over 60 years of age was not increased by anti-TNF therapy (OR: 0.90; 95% CI: 0.64–1.26).

An increased risk of neurological disorders has also been identified. The relationship between IBD and neuroinflammation is complex, but the bidirectional interaction within the gut–brain–microbiome axis may play a fundamental role in the pathogenesis of dementia-related diseases.168 Indeed, some studies have shown an increased risk of Parkinson’s disease, autism, and Alzheimer’s disease.49,168,169

The World Health Organization defines polypharmacy as the concurrent and excessive use of several medicines at a given time.170 However, most studies describe it quantitatively as the concurrent use of five or more medicines, with “severe polypharmacy” referring to use of more than ten drugs.171 Within this concept, it is important to distinguish between appropriate polypharmacy (medications required for the treatment of disease), inappropriate polypharmacy (off-label use, self-medication, chronic misuse of drugs), and the use of high-risk medicines due to their potential for interactions, as each has different clinical implications.172

Polypharmacy is currently a major health problem, associated with adverse effects, poor therapeutic adherence, cognitive changes, falls, undertreatment of chronic conditions, drug–drug interactions, hospital admissions, and even mortality.173–178 A recent systematic review estimated the prevalence of polypharmacy in the adult population at 37% (31–43%), rising to 45% (37–54%) in those over 65 years of age, particularly in the presence of chronic diseases and comorbidities.176–179

IBD is a chronic condition requiring long-term medication and is associated with different comorbidities, so the presence of polypharmacy is to be expected.178–183 To this, we must add the impact of patient ageing and disease progression.184–186 Nevertheless, polypharmacy in IBD has been little studied, and published data show it also affects this population, with prevalence ranging widely from 18 to 50%. It is particularly relevant in older patients, in whom rates of up to 86% have been reported, with 45% severe polypharmacy and 35% inappropriate medication use.187–189 Other associated factors include the presence of comorbidities (particularly psychiatric disorders), patient dependency, and long disease duration.187,189–191

The drugs most frequently consumed are analgesics, antihypertensives, proton pump inhibitors, and psychotropic agents.181 A Danish study observed that drug consumption was associated with recent diagnosis of IBD, particularly in older patients, with increased use of antidepressants, opioids, and analgesics, among others.192

The prognosis and clinical implications of polypharmacy in this setting are less well known. Beyond the potential harm of some widely used drugs, studies have linked polypharmacy with poorer quality of life, lack of adherence to treatment, and even a higher likelihood of clinical relapse in IBD.187–189

It is essential to have adequate tools to manage polypharmacy in patients with chronic diseases. This requires a thorough review of all the drugs a patient is taking, in order to identify polypharmacy and address it through a multidisciplinary approach. Collaboration across specialties—especially geriatrics—is key to minimising the use of inappropriate or high-risk medicines, thereby optimising the comprehensive management of associated diseases and improving patient outcomes.

Based on the available evidence,193 systematic and regular reviews of medication are recommended, prioritising only essential drugs and avoiding those that may adversely affect gastrointestinal function, such as non-steroidal anti-inflammatory drugs (NSAIDs), certain antibiotics, or diuretics in patients with ileostomies.194Table 6 shows interactions with the drugs most commonly used in IBD.

Deprescribing should be performed safely and gradually, avoiding adverse effects such as rebound or withdrawal syndromes, with close monitoring of the patient’s clinical course. Patient education and empowerment are also crucial, encouraging active participation in treatment optimisation and promoting lifestyle changes as a complementary strategy.

Interdisciplinary coordination between gastroenterologists, primary care physicians, and pharmacists is also essential to effectively reduce polypharmacy and improve clinical outcomes in patients with IBD.

Psychosocial factors are crucial in the comprehensive management of patients with IBD, especially those who are frail and/or older. The interplay between physical frailty and psychological vulnerability often leads to suboptimal clinical outcomes and reduced quality of life. IBD can significantly affect psychosocial functioning through the chronic stress of managing a long-term condition. Frailty and advanced age can exacerbate this burden, resulting in an increased risk of psychiatric disorders such as depression and anxiety.191,192 The gut–brain connection is well recognised, with studies showing that systemic inflammation can affect brain function and vice versa.195

Social isolation is another critical factor that negatively impacts the health of older IBD patients. A lack of a solid support network is associated with poorer therapeutic follow-up and reduced treatment adherence.196 Some studies suggest that social support independently improves health outcomes197; indeed, absence of a partner has been associated with greater loneliness and social isolation. Partners can provide crucial support, potentially buffering the effects of stress.12,198 Among older patients with IBD, 24% experience deterioration in social domains.63 Building support systems—whether family-based, social, or patient groups—is vital to improve emotional and social wellbeing.198 One study has indicated that strong social support reduces the risk of disease progression in middle-aged patients with CD.199 Although improving social support in patients with IBD appears to be a promising strategy, its impact has not yet been adequately evaluated.

New patient care modalities also need to be considered from a social perspective. Digital technologies have transformed patient management, increasing the use of telemedicine (by phone or email). On the one hand, this reduces travel for patients with restricted mobility and lowers stress associated with hospital visits. On the other, effectiveness depends on digital literacy and access to suitable devices. In-person care remains indispensable when detailed clinical evaluation or urgent intervention is required. It is therefore important to individualise decisions, taking into account both medical and social needs in each case.199,200

Finally, tailored psychosocial interventions such as cognitive behavioural therapy, stress management, and group interventions have been shown to improve quality of life in IBD patients.182,201 It is essential to implement strategies that foster psychological resilience and patient autonomy, while addressing the specific barriers faced by frail and older patients. Healthcare professionals should be aware of the impact of frailty and age on mental and social health, and work to integrate supportive strategies into routine care202 (Fig. 4).

Figure 4.

Proposed interventions to improve geriatric aspects of the patient with inflammatory bowel disease.

Indicating investigations in frail patients with IBD is highly complex. The fundamental principle is that decisions must be individualised. No guideline or tool can offer absolute certainty as to whether a given investigation is indicated in a specific patient. What can be defined are the factors to evaluate and the basic principles to guide decision-making. In this section, we focus on colonoscopy as an example, since it is the most common invasive procedure in this population203; however, the considerations apply equally to other investigations. The main factors to consider when determining the appropriateness of an investigation are:

• 1

  Degree of frailty. Relatively simple classifications can be used to determine the level of frailty. While in specific cases a full Comprehensive Geriatric Assessment (CGA) may be required, a quicker scale such as the Clinical Frailty Scale (CFS) will usually suffice. According to frailty level, patients can be grouped as follows:

  • (a)

    Advanced frailty. IF-VIG > 0.5 or CFS ≥ 7; patients are fully dependent, bedbound or terminal. Diagnostic–therapeutic goals are to ensure comfort and symptom control. Endoscopic procedures are not indicated due to their short life expectancy and high risk of complications.

  • (b)

    Mild-moderate frailty. IF-VIG 0.2–0.5 or CFS 5–6. The goals are to achieve clinical benefit by promoting autonomy and quality of life, but not to prolong survival. Screening procedures are not indicated, as they are not useful given the limited life expectancy. Diagnostic or therapeutic procedures may be considered only if results are expected to lead to interventions that clearly improve functional status or quality of life.

  • (c)

    No frailty or pre-frailty. IF-VIG < 0.2 or CFS 1–4. Diagnostic–therapeutic goals are the same as in the general population, and no restrictions are applied.

• 2

  Indication for the test: as already partially discussed in the previous section, we will have to determine in which category we classify the test. We will distinguish:

  • (a)

    Screening tests: These would only be indicated in patients without frailty. In general, this is linked to a long life expectancy. In the uncommon case of patients without frailty but with life expectancy limited by comorbidities —e.g., cardiovasculardisease — the risk–benefit of colonoscopy should be assessed and the procedure only indicated if the balance is unequivocally favourable.

  • (b)

    Diagnostic and/or therapeutic procedures: These would be indicated in all patients without advanced frailty. In such cases, the potential risk of complications and the expected benefit of colonoscopy must be carefully weighed, and the procedure should only be recommended if the risk–benefit balance is clearly favourable, following the classical principle of primum non nocere.

• 3

  Principles, preferences and values of each patient: The criteria set out above are subordinate to the principle of patient autonomy. That is, we must respect the decision of a patient who refuses any examination if they prefer to maintain a less medicalised lifestyle (regardless of frailty status). This is particularly relevant given the limited scientific evidence on the usefulness of screening colonoscopy in reducing mortality in patients with IBD. In such cases, our only obligation is to provide unbiased information on the risks and benefits of undergoing or foregoing the test, and to ensure that the patient understands this information. The only exception is that, in line with the ethical principle of non-maleficence, we have an ethical duty to refuse to recommend or perform a procedure if, in our professional judgement, the risk–benefit balance is unfavourable for the patient.204

This position paper was developed based on a critical review of the literature and expert consensus from the Spanish Working Group on Crohn’s Disease and Ulcerative Colitis (GETECCU). No individual patient data were used, nor was the conduct of clinical studies required; therefore, approval from a research ethics committee was not necessary. The document was developed in accordance with the ethical principles of independence, transparency, and scientific rigour.

No funding was received for this paper.