Step Up vs. Top Down in IBD Approach

Recently, in inflammatory bowel disease (IBD) management, other goals have been advocated, such as improving a patient’s quality of life, reducing hospitalization and surgery, and mucosal healing. In the last 2–3 years, mucosal healing is the final and most important goal in IBD therapy.
The means to achieve these goals may differ depending on the clinical presentation. Similar to the heterogeneity of clinical presentation, the natural history of IBD is equally diverse and the ideal is to have tools to aid in the prediction of a severe disease course versus a more indolent type of disease, so that a more aggressive therapeutic approach can be instituted earlier instead of a more graduated approach [1,2].
Clinical parameters, largely derived from retrospective studies that predict a more aggressive disease course, include a younger age of disease onset, active smoking, extensive small bowel disease, deep colonic ulcers, perianal disease, and an initial need for corticosteroids [3,4,5].
The standard therapies for IBD available to a clinician include 5-aminosalicylates, sulfasalazine and mesalazine, corticosteroids, immunosuppressive agents, and monoclonal antibodies (MAbs), so called biologic agents. [More]