At a glance
- Never stop an IBD medicine on your own. Talk to your IBD team first, and stop only with a plan.
- Lowering or stopping is only considered when your bowel has healed on a scope or scan, not just when you feel well.
- After stopping a biologic like infliximab or adalimumab, about 1 in 3 people flare within a year, and about half within a few years.
- If a flare happens, restarting the same medicine works for most people, but not everyone.
- If you take two medicines together, dropping one of them is often safer than stopping the biologic.
- If you stop, plan for stool and blood tests about every 3 months in the first year, even if you feel well.
- If you have taken azathioprine or mercaptopurine, keep getting a skin check every year, even after you stop.
- Know your rescue plan: who to call and what happens if symptoms come back.
Why people think about stopping
Lowering the dose of a medicine, or stopping it, under a doctor’s care is called deprescribing. People ask about it for good reasons:
- Worry about side effects, such as infections or cancer
- Being older. The risks of some medicines go up with age.
- Planning a pregnancy, when a medicine is not safe in pregnancy (such as methotrexate)
- Cost, travel, or just wanting to take fewer medicines
These are all fair reasons to ask. Dr. Squirell and her colleagues wrote a review on how to do this safely. It found that stopping can work for carefully chosen people, with close follow-up and a plan if IBD comes back.
Who might be able to stop?
Your team will look at three things.
- Is your bowel healed? Feeling well is not enough. A colonoscopy, ultrasound or MRI should show the inflammation is gone. This is called deep remission.
- For how long? The risk of a flare is higher if you have been in remission for less than 2 to 4 years.
- What is your risk of a flare? Some things make a flare more likely after stopping:
- Being younger (under about 30 to 40)
- Smoking
- Crohn’s disease around the anus (perianal disease), or a narrowing (stricture)
- Past bowel surgery
- A raised stool calprotectin or blood CRP test
- Being male (in some studies)
If your risk is high, your team may suggest staying on your medicine. If your worry is a side effect, they may suggest switching to a different medicine instead of stopping.
How likely is a flare?
These numbers come from studies of people who stopped while they were doing well. Your own risk may be higher or lower.
Three studies also followed people who kept taking their medicine. They show how much stopping adds to the chance of a flare.
Colitis, anti-TNF, bowel fully healed first (BIOSTOP). By 2 years
- Stopped the anti-TNF52 in 100
- Kept taking it12 in 100
Crohn's, infliximab plus azathioprine (SPARE). By 2 years
- Stopped infliximab36 in 100
- Stopped azathioprine10 in 100
- Kept taking both14 in 100
Crohn's, azathioprine or mercaptopurine alone. By 18 months
- Stopped it37 in 100
- Kept taking it21 in 100
Each heading says who was in the study, and how long they were followed.
| Medicine stopped | Chance of a flare | If a flare happens |
|---|---|---|
| Anti-TNF (infliximab, adalimumab) | About 1 in 3 within 1 year. About 1 in 2 after a few years. | Restarting the same medicine works for about 8 in 10 people. |
| Anti-TNF, when the bowel was fully healed first (Crohn’s) | About 1 in 4 within 1 year | Same as above |
| Anti-TNF, when the bowel was fully healed first (colitis, BIOSTOP study) | About 1 in 2 by 2 years | Restarting worked for about 3 in 4 people |
| Infliximab, while staying on azathioprine (SPARE study) | About 1 in 3 by 2 years | 22 of 23 people treated for a flare got back into remission |
| Azathioprine, while staying on infliximab (SPARE study) | About 1 in 10 by 2 years | 2 of 3 people treated for a flare got back into remission |
| Azathioprine or mercaptopurine alone (Crohn’s) | 37 in 100 by 18 months | Not well studied |
| Vedolizumab | About 4 in 10 by 1 year, and about 2 in 3 by 18 months (one study) | Restarting worked for about 6 in 10 |
| JAK pills for colitis (tofacitinib, upadacitinib) | About 8 in 10 within 2 years (one small study of 16 people) | Restarting worked for about 8 in 10 |
What this means:
- Stopping has trade-offs. A 2025 review of 4 trials looked at stopping an anti-TNF. Flares were about 3 times as likely. But infections were about half as likely.
- If you take two medicines together (a biologic plus azathioprine or methotrexate), dropping the azathioprine or methotrexate is often the safer first step.
- Vedolizumab, ustekinumab and the IL-23 medicines have fewer serious side effects. Flares after stopping seem common. So few people gain much from stopping them. Stopping the newest IL-23 medicines has not been studied yet.
- Restarting usually works, but not always. Some people do not respond as well the second time. That is why stopping is never risk-free.
What about 5-ASA and steroids?
- 5-ASA (like mesalamine) is usually kept long-term in ulcerative colitis to help keep it calm. But if 5-ASA was not enough and you moved on to a biologic, an advanced pill or azathioprine, your team may suggest stopping the 5-ASA. Ask your team before you change it.
- Steroids (like prednisone) are always meant to be lowered and stopped. Follow the taper your team gives you. Never stop them suddenly.
Thiopurines and cancer risk
Azathioprine and mercaptopurine are called thiopurines. Taken for a long time, they raise the risk of:
- Lymphoma (a blood cancer). This risk is still low. It goes back down after you stop.
- Skin cancer (not melanoma). This risk stays higher even after you stop.
So if you have ever taken a thiopurine, keep getting a skin check every year and protect your skin from the sun for life. These risks are one reason doctors may suggest stopping a thiopurine in people over 60.
If you decide to stop: your safety plan
Before you stop, agree on a plan with your team:
Before you stop
Baseline tests
Have tests while you are well, so you know your “normal.”About every 3 months in the first year
Stool and blood tests
Have a stool calprotectin test and blood tests, even when you feel fine. A rise can show a flare before you feel it.If tests rise or symptoms return
A scope or scan
Your team looks at the bowel again. Some teams also check at 6 to 12 months.Agreed before you stop
A rescue plan
Know who to call and how fast you can restart treatment. Write down your flare plan, too. See Make your flare plan.
Ready to talk about it? A quick check
This short check can help you get ready for the talk with your team. It is for discussion only. It does not decide anything.
1. Which medicine are you thinking about?
2. Do you feel well, with no flare symptoms right now?
3. Did your last scope, ultrasound or MRI show healing?
Feeling well is not enough. The bowel should look healed.
4. Was your last stool calprotectin normal?
5. How long have you been in remission?
6. What is your main reason?
7. Do any of these apply to you?
Tick all that apply, or 'None of these'.
What this suggests
Answer 7 more items to see the result.
- Which medicine
- How you feel
- Healing on a test
- Calprotectin
- Time in remission
- Your main reason
- Things that raise flare risk
For discussion only. Never stop or lower an IBD medicine without talking to your IBD team.
Can I lower the dose instead of stopping?
Sometimes. For some medicines, your team may space out doses or lower the dose. This also carries some risk of a flare, so it needs the same follow-up plan.
I feel great. Why isn't that enough?
Many people feel well while some inflammation is still there. Stopping in that case makes a flare much more likely. That is why your team checks with a scope or scan first.
Sources for this guide
Sources
- Squirell E, Hearn J, MacMillan M. Deprescribing advanced therapies in inflammatory bowel disease. Canadian IBD Today 2025;3(2):5–12. Dr. Squirell's review. Step-by-step approach: deep remission (endoscopic and/or imaging), risk assessment, shared decision, monitoring and a rescue plan. Relapse risk factors (younger age, male sex, smoking, ileocolonic, perianal or stricturing disease, past surgery, raised calprotectin or CRP, remission under 2–4 years). Thiopurine withdrawal 33% vs 15% relapse at 12 months and 37% vs 21% at 18 months; lymphoma risk returns toward baseline. Vedolizumab withdrawal 64% relapse within a year, retreatment success 63% (Martin A, et al. J Crohns Colitis 2020;14:896–903, PMID 31930285: 61 of 95 relapsed over a median 11.2 months; relapse-free survival 59% at 12 months and 36% at 18 months). JAK inhibitor withdrawal in UC 81% vs 8%, retreatment 83% (Sano Y, et al. Crohns Colitis 360 2025;7:otaf020, PMID 40230498: 13 of 16 who stopped relapsed, the last on day 717 after stopping). Calprotectin and/or CRP every 3 months in year 1.
- Gisbert JP, Marín AC, Chaparro M. The risk of relapse after anti-TNF discontinuation in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 2016;111:632–47. PMID 27002797 27 studies. About one-third relapse 1 year after stopping anti-TNF, about half in the long term (CD 40% at 12 months, 49% after 25+ months; UC 28% at 12 months). In CD, 26% at 1 year when endoscopic remission was required vs 42% with clinical remission alone. Restarting the same anti-TNF worked in 80%.
- Kennedy NA, Warner B, Johnston EL, et al. Relapse after withdrawal from anti-TNF therapy for inflammatory bowel disease: an observational study, plus systematic review and meta-analysis. Aliment Pharmacol Ther 2016;43:910–23. PMID 26892328 Pooled 1-year relapse 39% (CD) and 35% (UC); retreatment successful in 88% (CD) and 76% (UC).
- Louis E, Mary JY, Vernier-Massouille G, et al. Maintenance of remission among patients with Crohn's disease on antimetabolite therapy after infliximab therapy is stopped (STORI). Gastroenterology 2012;142:63–70. PMID 21945953 1-year relapse 43.9% after stopping infliximab; restarting infliximab worked in 88%; low-risk patients had about 15% relapse at 1 year.
- Louis E, Resche-Rigon M, Laharie D, et al. Withdrawal of infliximab or concomitant immunosuppressant therapy in patients with Crohn's disease on combination therapy (SPARE). Lancet Gastroenterol Hepatol 2023;8:215–27. PMID 36640794 2-year relapse: 14% staying on both, 36% stopping infliximab, 10% stopping the immunosuppressant. 22 of 23 who relapsed after stopping infliximab regained remission.
- Berset IP, Lerang F, Moum B, et al. Anti-TNF withdrawal or long-term treatment in ulcerative colitis (BIOSTOP): a multicentre open label, randomized controlled trial. J Crohns Colitis 2026;20(8). PMID 42557857 172 people with UC in deep (clinical, biochemical and endoscopic) remission. Over 2 years, flares in 52% (45/86) after stopping vs 12% (10/86) staying on anti-TNF; restarting anti-TNF worked in 74% (20/27); 48% of the stop group stayed in steroid-free remission; no factor predicted who would flare.
- Owolabi AA, Qazi I, Ahmed N, Alsayed MA, et al. TNF antagonists withdrawal is not advised in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis of randomized controlled trials. Int J Colorectal Dis 2025;40:245. PMID 41331357 4 RCTs, 485 patients: stopping anti-TNF raised relapse risk (RR 3.00) and shortened time to relapse, but lowered infection risk (RR 0.47); serious adverse events similar.
- Singh S, Loftus EV Jr, Limketkai BN, et al. AGA living clinical practice guideline on pharmacological management of moderate-to-severe ulcerative colitis. Gastroenterology 2024;167:1307–43. PMID 39572132 In UC that failed 5-ASA and was escalated to immunomodulators or advanced therapy, suggests stopping 5-ASA. In UC in steroid-free remission for 6+ months on anti-TNF plus immunomodulator, suggests against withdrawing the anti-TNF; no recommendation for or against withdrawing the immunomodulator.
- French H, Dalzell AM, Srinivasan R, El-Matary W. Relapse rate following azathioprine withdrawal in maintaining remission for Crohn's disease: a meta-analysis. Dig Dis Sci 2011;56:1929–36. PMID 21476031 Stopping azathioprine/6-MP raised relapse risk at 6, 12 and 18 months; no clear difference at 5 years (2 trials).
- Peyrin-Biroulet L, Khosrotehrani K, Carrat F, et al. Increased risk for nonmelanoma skin cancers in patients who receive thiopurines for inflammatory bowel disease (CESAME). Gastroenterology 2011;141:1621–28. PMID 21708105 Non-melanoma skin cancer risk raised with current (HR 5.9) and past (HR 3.9) thiopurine use; lifelong skin checks advised.
- Beaugerie L, Brousse N, Bouvier AM, et al. Lymphoproliferative disorders in patients receiving thiopurines for inflammatory bowel disease: a prospective observational cohort study (CESAME). Lancet 2009;374:1617–25. PMID 19837455 Lymphoma risk raised during thiopurine use (HR 5.28); in people who had stopped, the rate was similar to people who never took them.
- Bressler B, Panaccione R, Fedorak RN, Seidman EG. Clinicians' guide to the use of fecal calprotectin to identify and monitor disease activity in inflammatory bowel disease. Can J Gastroenterol Hepatol 2015;29:369–72. PMID 26125109 Calprotectin 100–250 µg/g: inflammation possible, look further; over 250: active inflammation likely.
- Bressler B, Marshall JK, Bernstein CN, et al. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Gastroenterology 2015;148:1035–58. PMID 25747596 5-ASA is used to maintain remission in UC.
This guide is for general education. It can't replace advice from your own care team, who know your health history.