title: Practical Approaches to "Top-Down" Therapies for Crohn's Disease.
abstract: Crohn's disease (CD) is a chronic, progressive, and disabling disease that leads in most cases to the development of bowel damage presenting as a fistula, abscess, or stricture. For years, therapy for Crohn's disease has been based on a "step-up" approach, in which anti-TNF agents are administered after the failure of steroids and immunosuppressants. However, recent studies have suggested that early introduction of anti-TNF agents combined with immunosuppressants can modify the natural history of the disease. Patients who could benefit more of this "top-down" strategy would be those at elevated risk of a complicated or severe inflammatory bowel disease or with factors that can predict an aggressive disease course. Therefore, the management of a patient with CD should be personalized, taking into account the patient's specific characteristics and comorbidities, disease activity, site and behavior of the disease, and predictable factors of poor prognosis. A balance between medication and potential adverse effects should be achieved, trying to avoid under or overtreatment, always discussing the different therapeutic options with the patient. The natural history of ulcerative colitis differs from CD and, to date, there is not much scientific evidence on the use of early combined immunosuppression.
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. aran.jauregui@gmail.com.
authors.forename: Aranzazu Jauregui
authors.initials: AJ
authors.lastname: Amezaga
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
authors.forename: Gert
authors.initials: G
authors.lastname: Van Assche
mesh_terms: D000068879:Adalimumab / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D003424:Crohn Disease / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000069285:Infliximab / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D012307:Risk Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D007166:Immunosuppressive Agents; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab
keywords: Adalimumab; Anti-TNF; Crohn’s disease; Early combined immunosuppression; Immunosuppressants; Infliximab