Medical Therapy for Crohn’s Disease: Top-Down or Step-Up?
- 1 September 2007
- journal article
- research article
- Published by S. Karger AG in Digestive Diseases
- Vol. 25 (3), 260-266
- https://doi.org/10.1159/000103897
Abstract
The emergency of effective biological therapy in the treatment of Crohn's disease (CD) has led to a clinical debate about 'step-up versus top-down strategy'. Step-up refers to the classic therapeutic approach, namely progressive intensification of treatment as disease severity increases. Top-down refers to the early introduction, in all CD patients, of intensive therapies, including biological agents and immunosuppressive drugs, with the aim of avoiding complications and improving quality of life, starting from the assumption that these drugs may interfere with the natural history of the disease. Very recently the Belgian IBD research group together with the Gut Club of North Holland designed 'the Step Up versus Top Down Trial'. Combination of infliximab with immunosuppressives at onset was better than the current standard approach in terms of both induction and maintenance of remission. However, several observations still limit the use of infliximab as first-line treatment in adult CD patients. In particular, the epidemiological observation that over 50% of CD patients have a mild disease over time and will never require aggressive therapies is against the indiscriminate use of top-down strategy. Lack of markers able to identify high-risk patients, discussions about long-term safety and the high costs of infliximab are further factors supporting a more careful approach to the management of CD.Keywords
This publication has 19 references indexed in Scilit:
- Serologies in Crohn’s Disease: Can We Change the Gray Zone to Black and White?Gastroenterology, 2006
- Serious Infections and Mortality in Association With Therapies for Crohn’s Disease: TREAT RegistryClinical Gastroenterology and Hepatology, 2006
- Anti-TNF Antibody Therapy in Rheumatoid Arthritis and the Risk of Serious Infections and MalignanciesJAMA, 2006
- Infliximab Plus Azathioprine for Steroid-Dependent Crohn’s Disease Patients: A Randomized Placebo-Controlled TrialGastroenterology, 2006
- Evolution of clinical behaviour in Crohn's disease: predictive factors of penetrating complicationsDigestive and Liver Disease, 2005
- Impact of the increasing use of immunosuppressants in Crohn's disease on the need for intestinal surgeryGut, 2005
- Balancing the risks and benefits of infliximab in the treatment of inflammatory bowel diseaseGut, 2004
- Tuberculosis Associated with Infliximab, a Tumor Necrosis Factor α–Neutralizing AgentThe New England Journal of Medicine, 2001
- Frequency of glucocorticoid resistance and dependency in Crohn's disease.Gut, 1994
- Inflammatory Bowel DiseaseJournal of Clinical Gastroenterology, 1992