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Step-Up vs. Top-Down Approach in Medical Management of Inflammatory Bowel Disease

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Crohn's Disease and Ulcerative Colitis

Abstract

During recent years, the treatment for patients with Crohn’s disease (CD) has changed substantially. With the introduction of anti-TNF alpha antibodies, the treatment goals have been more ambitious, for instance, with the introduction of mucosal healing. Today, upon diagnosing CD, clinicians are able to use predictors of a complicated disease course and act accordingly when designing an individual medical strategy.

CD typically progresses from an inflammatory disease phenotype in the early stage of the disease to a more severe complicated disease phenotype, characterized by fibrosis and stenosis. At this point, the disease is difficult to treat and fibrotic lesions are often irreversible. Therefore, intensive therapy in an early disease stage, within the so-called Window of Opportunity, is favorable in patients who are likely to develop a complicated disease phenotype. This disease-modifying strategy is aimed at avoiding late stage disease-related complications and at inducing steroid-free remission as soon as possible. Indeed, with this approach, higher response rates, higher rates of mucosal healing, and a higher percentage of patients achieving steroid-free remission are observed. However, not all patients will need this early intensive approach, and long-term safety is one of the concerns.

In this chapter, we discuss which patients can be selected for an early intervention approach, which safety measures should be undertaken, how patients should be monitored, and how therapy might be de-escalated once remission has been achieved.

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Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands

    Anne Christine W. Vos MSc & Daniel W. Hommes MD, PhD

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  1. Anne Christine W. Vos MSc
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  2. Daniel W. Hommes MD, PhD
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  1. Medical School of the Humboldt Universit, Department of Medicine, Charité Medical Center, Virchow Hospita, Berlin, 13344, Germany

    Daniel C. Baumgart

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Vos, A.C.W., Hommes, D.W. (2012). Step-Up vs. Top-Down Approach in Medical Management of Inflammatory Bowel Disease. In: Baumgart, D. (eds) Crohn's Disease and Ulcerative Colitis. Springer, Boston, MA. https://doi.org/10.1007/978-1-4614-0998-4_44

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  • DOI: https://doi.org/10.1007/978-1-4614-0998-4_44

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