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Early use of immunosuppressives or TNF antagonists for the treatment of Crohn's disease: time for a change
  1. Ingrid Ordás1,2,
  2. Brian G Feagan3,
  3. William J Sandborn1
  1. 1Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
  2. 2Division of Gastroenterology, Hospital Clinic, CIBER-EHD, IDIBAPS, University of Barcelona, Barcelona, Spain
  3. 3Division of Gastroenterology, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
  1. Correspondence to Dr William J Sandborn, Division of Gastroenterology, University of California San Diego, 9500 Gilman Drive, Building UC 303, Room 220, La Jolla, CA 92093-0063, USA; wsandborn{at}


Crohn's disease is a chronic inflammatory disorder that follows a progressive and destructive course. Ultimately, uncontrolled inflammation leads to bowel damage from disease-related complications such as strictures, fistulas and abscesses and surgical resection. Conventional ‘step-care’, whereby corticosteroids and immunosuppressives are prescribed sequentially, is an incremental approach to treatment that does not prevent disease progression and conveys an important risk of adverse events from repeated courses of corticosteroids. Although the immunosuppressives azathioprine, 6-mercaptopurine and methotrexate are corticosteroid-sparing, they are not highly effective for inducing mucosal healing or preventing disease progression. Tumour necrosis factor antagonists induce and maintain mucosal healing and reduce surgery and hospitalisation rates. This holds out the possibility that long-term use of these agents may prevent bowel damage. Combination therapy with immunosuppressives and tumour necrosis factor antagonists is likely the best strategy for achieving optimal outcomes in patients at high risk of disease progression. However, accurate prognostic markers must be identified to guide patient selection. Long-term prospective studies with robust outcomes are still needed to establish definitively the efficacy and safety of early combination therapy to prevent bowel damage, loss of gastrointestinal tract function and permanent disability.

  • Crohn's disease
  • immunesuppressives
  • TNF antagonists
  • mucosal healing
  • disability
  • IBD
  • gastrointesinal endoscopy
  • inflammatory bowel disease
  • ulcerative colitis
  • IBD clinical

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  • Competing interests WJS has received consulting fees from Abbott Laboratories, ActoGeniX NV, AGI Therapeutics, Alba Therapeutics Corporation, Albireo, Alfa Wasserman, Amgen, AM-Pharma BV, Anaphore, Astellas Pharma, Athersys, Atlantic Healthcare, Axcan Pharma (now Aptalis), BioBalance Corporation, Boehringer-Ingelheim, Bristol Meyers Squibb, Celegene, Celek Pharmaceuticals, Cellerix SL, Cerimon Pharmaceuticals, ChemoCentryx, CoMentis, Cosmo Technologies, Coronado Biosciences, Cytokine Pharmasciences, Eagle Pharmaceuticals, Eisai Medical Research, Elan Pharmaceuticals, EnGene, Eli Lilly, Enteromedics, Exagen Diagnostics, Ferring Pharmaceuticals, Flexion Therapeutics, Funxional Therapeutics, Genzyme Corporation, Genentech (now Roche), Gilead Sciences, Given Imaging, GlaxoSmithKline, Human Genome Sciences, Ironwood Pharmaceuticals (previously Microbia), Janssen (previously Centocor), KaloBios Pharmaceuticals, Lexicon Pharmaceuticals, Lycera Corporation, Meda Pharmaceuticals (previously Alaven Pharmaceuticals), Merck Research Laboratories, MerckSerono, Millennium Pharmaceuticals (subsequently merged with Takeda), Nisshin Kyorin Pharmaceuticals, Novo Nordisk A/S, NPS Pharmaceuticals, Optimer Pharmaceuticals, Orexigen Therapeutics, PDL Biopharma, Pfizer, Procter and Gamble, Prometheus Laboratories, ProtAb, Purgenesis Technologies, Receptos, Relypsa, Salient Pharmaceuticals, Salix Pharmaceuticals, Santarus, Schering Plough Corporation (acquired by Merck), Shire Pharmaceuticals, Sigmoid Pharma, Sirtris Pharmaceuticals (a GSK company), S.L.A. Pharma (UK), Targacept, Teva Pharmaceuticals, Therakos, Tillotts Pharma AG (acquired by Zeria Pharmaceutical), TxCell SA, UCB Pharma, Viamet Pharmaceuticals, Vascular Biogenics Limited (VBL), Warner Chilcott UK Limited, Wyeth (now Pfizer), lecture fees from Abbott Laboratories, Bristol Meyers Squibb and Janssen (previously Centocor) and research support from Abbott Laboratories, Bristol Meyers Squibb, Genentech, Glaxo Smith Kline, Janssen (previously Centocor), Millennium Pharmaceuticals (now Takeda), Novartis, Pfizer, Procter and Gamble Pharmaceuticals, Shire Pharmaceuticals and UCB Pharma. BGF has received research support, consulting and lecture fees from Janssen (previously Centocor), Merck (previously Schering Plough), Abbott Laboratories and UCB Pharma. IO (author name, Ingrid Ordas) has no competing interests.

  • Provenance and peer review Commissioned; externally peer reviewed.