The new step down therapy for inflammatory bowel disease

Dr John P Wright

Updated: 10 April 2007

Traditionally medical management has aimed at controlling the symptoms of inflammatory bowel disease. When simple anti-diarrhoeals and antispasmodics don’t work we have resorted to corticosteroids and surgery. The rapid response to the former and the pious hope of cure after the latter has driven this symptomatic approach for many years. It is now becoming apparent that this approach has sown a generation of medically and surgically crippled patients. While the deleterious effects of steroids on skin, bones, psyche and immune system are well known the effects of surgical misadventure are less well recognized. Short bowel syndrome, colostomies, ileostomies, post-op catastrophes and long term surgically induced sepsis are part of the spectrum of the life of inflammatory bowel disease patients submitted to surgery. Clearly this combination of medical and surgical attack was not sustainable. A new approach was needed.

The first step in the new paradigm was the introduction of azathioprine into the routine maintenance management of patients with Crohn's disease. At last a relatively safe alternative to steroids was available. The introduction of the anti-TNF antibodies has pushed this new paradigm further on towards the control of the underlying pathological process of inflammatory bowel disease. Infliximab (Revellex) has been shown to induce remission in patients with acute Crohn's disease in 60% to 80% of patients. The chronic use of infliximab has also been shown to hold patients in remission particularly if they are also on a traditional immunosuppressant such as azathioprine. The expected introduction of adalimumab (Humira) later this year will broaden the possible role of biologicals in the control of inflammatory bowel disease. This is due to it being a fully humanized antibody which might cause less allergic side effects.

The underlying concept of step down therapy has been more fully explored by the rheumatologists who have shown that the early control of the inflammatory process in patients with rheumatoid arthritis leads to prolonged disease suppression. This is less developed in gastroenterology but the evidence is accumulating that patients given disease modifying therapy have a better prognosis than those simply treated with steroids. Furthermore there is evidence that the use of corticosteroids may make the disease process more difficult to control in the long term.

On this basis it is becoming accepted that all patients with proven inflammatory bowel disease should be placed on long term immunosuppressive therapy early in their clinical course. Further acute attacks should be suppressed with an anti-TNF agent such as infliximab (Revellex). This therapy should be continued as maintenance therapy until all signs of the disease process are controlled. This approach has been shown to reduce the long term cost of controlling inflammatory bowel disease as well as leaving patients clinically well and on less therapy.

We are now awaiting more evidence to support this early aggressive approach to the underlying disease process in inflammatory bowel disease.