Conservative Therapy: Step Up or Top Down?

Conservative Therapy: Step Up or Top Down? During the last years, monoclonal antibodies against the cytokine tumor necrosis factor alpha were introduced in the treatment of chronic inflammatory bowel diseases. Study results showing therapeutic efficacy in Crohn's disease are available for the antibody preparations infliximab, adalimumab, and certolizumab. As these drugs have a quick and strong effect on immune suppression, the right time for application in the course of the chronic disease is of utmost importance. The sequential use of steroids und conventional immune suppressants which is only followed by application of antibody preparations in case of treatment failure is termed step up therapy and in such described in numerous guidelines. Top down strategy is described as the use of antibody preparations after diagnosis of Crohn's disease the dose of which may be reduced during the course of therapy. New study showed that early application of antibody preparations results in quick remission. However, it should be kept in mind that a considerable number of patients with Crohn's disease only temporarily or not at all need immune suppressants during therapy. In these cases, the risks associated with strong immune suppression would argue against the application of antibody preparations after diagnosis of the disease. Thus far, it is not possible to foretell the activity of Crohn's disease during the course of the illness. Moreover, according to one study there is no difference after 2 years with regard the number of patients in remission when comparing step up and top down approaches. Therefore, the step up strategy is recommended, though amended by the advice to begin with antibody treatment in individual patients with continuously high activity of disease. In case of treatment failure treatment escalation steps can be done quickly so that in cases with problematic course of disease top down and step up strategies are not significantly different. Continuous treatment with steroids which has been applied frequently in the past should be avoided in any case.