Underutilization of Advanced Ibd Therapies and Delayed Escalation in a Minority-Predominant Urban Population

BACKGROUND African American (AA) patients face disproportionate barriers to inflammatory bowel disease (IBD) care, including lower biologic use and greater corticosteroid dependence. Structural barriers such as limited access, poor follow-up, and geographic disadvantage persist, yet few studies have examined these in AA-majority cohorts. Clarifying therapy access in this context is essential to addressing IBD inequities. Aim To characterize treatment patterns and assess associations with disease severity, follow-up adherence, and sociodemographic factors in a diverse IBD cohort. METHODS We retrospectively analyzed 197 IBD patients (88 Crohn’s disease [CD], 109 ulcerative colitis [UC]) diagnosed 2011-2024. Clinicopathological, pharmacologic, and follow-up data were abstracted from electronic records. Medications included 5-ASA, corticosteroids, immunosuppressants, biologics, and JAK inhibitors. Time-to-escalation was calculated from diagnosis to advanced therapy initiation. Associations were tested with chi-square, correlation, and logistic regression. RESULTS Among 197 patients (88 CD, 109 UC), treatment patterns differed by subtype. UC patients more often received 5-ASA (74/109, 67.9%) vs. CD (15/88, 17.0%; p < 0.001) and corticosteroids (41/109, 37.6% vs. 19/88, 21.6%; p = 0.015). Advanced therapies were uncommon: immunosuppressants 27/197 (13.7%), biologics 16/197 (8.1%), JAK inhibitors 1/197 (0.5%). Escalation correlated with histologic severity, with immunosuppressants in 18/50 severe (36%) vs. ≤9% in mild/none (p < 0.001), and biologics in 10/50 (20%) vs. ≤6% (p = 0.023). Time-to-escalation (n = 13) showed biologic/JAK initiation occurred ∼3 years after diagnosis. Follow-up strongly influenced therapy. Up-to-date patients were more often on 5-ASA (40/68, 58.8%, p = 0.001) and steroids (29/68, 42.6%, p = 0.007). Biologic use was absent among those lost to follow-up (0/18, p≈0.050). Biologics rose with regimen intensity (10% monotherapy, 58% dual, 67% triple; p < 0.001). UC cases clustered in disadvantaged wards, yet advanced therapies remained underused. In multivariate analysis (N = 132), female sex predicted immunosuppressant use (OR 4.5, p = 0.029). Lower BMI increased likelihood, with BMI 30–34.9 linked to reduced odds (OR 0.06, p = 0.023). White patients showed higher use than AA (46% vs. 12%; adjusted OR 15.6, p = 0.10). For biologics, CD (OR 8.5, p = 0.039) and younger age (OR 0.87/year, p = 0.004) predicted use, while retired status was linked to lower odds (OR 0.015, p = 0.048). CONCLUSION In this AA-predominant cohort, UC patients more often received 5-ASA and corticosteroids, while advanced therapies were underutilized. Escalation occurred with severe histology and was delayed ∼3 years. Follow-up adherence correlated with therapy. Persistent steroid reliance and racial/geographic disparities highlight critical gaps in timely, equitable IBD care.