Maintenance treatment in Inflammatory Bowel Disease (IBD)

Ulcerative colitis and Crohn's disease are complex disorders reflected by wide variation in clinical practice. Lifelong maintenance treatment is recommended for all patients with ulcerative colitis, especially those with left sided or extensive disease and those with distal disease, who relapse more than once a year. Oral mesalazine 2g/day should be considered as first-line therapy. Steroids are not effective at maintaining remission. Azathioprine 1,5-2,5 mg/kg/day or mercaptopurine 0,75-1,5 mg/kg/day should be reserved for patients who frequently relapse, despite adequate doses of aminosalicylates. Patients who have failed to respond to immunomodulators benefit from repeated maintenance therapy with infliximab, ideally on an every 8 week basis. The efficacy of drug therapy in the maintenance treatment of Crohn's disease depends on whether remission was achieved with medical or surgical therapy, on the risk of relapse and on the site of disease. Mesalazine seems to be ineffective at doses < 2 g/day. It is clearly ineffective for those who have needed steroids to induce remission. Azathioprine should be reserved as second line therapy. Steroid dependent patients and patients with steroid refractory disease should be considered for treatment with immunomodulators. Infliximab is effective at a dose of 5 mg/kg every 8 weeks in patients who have responded to the initial infusion. It is best used with immunomodulators. Moreover, it is the best evidenced-based therapy for the fistulating disease at the present time. Ulcerative colitis and Crohn's disease, collectively termed inflammatory bowel disease, are complex disorders reflected by wide variation in clinical practice.