Conventional medical management of inflammatory bowel disease

Gastroenterology. 2011 May;140(6):1827-1837.e2. doi: 10.1053/j.gastro.2011.02.045.


Conventional therapies for ulcerative colitis and Crohn's disease (CD) include aminosalicylates, corticosteroids, thiopurines, methotrexate, and anti-tumor necrosis factor agents. A time-structured approach is required for appropriate management. Traditional step-up therapy has been partly replaced during the last decade by potent drugs and top-down therapies, with an accelerated step-up approach being the most appropriate in the majority of patients. When patients are diagnosed with CD or ulcerative colitis, physicians should consider the probable pattern of disease progression so that effective therapy is not delayed. This can be achieved by setting arbitrary time limits for administration of biological therapies, changing therapy from mesalamine in patients with active ulcerative colitis, or using rescue therapy for acute severe colitis. In this review, we provide algorithms with a time-structured approach for guidance of therapy. Common mistakes in conventional therapy include overprescription of mesalamine for CD; inappropriate use of steroids (for perianal CD, when there is sepsis, or for maintenance); delayed introduction or underdosing with azathioprine, 6-mercaptopurine, or methotrexate; and failure to consider timely surgery. The paradox of anti-tumor necrosis factor therapy is that although it too is used inappropriately (when patients have sepsis or fibrostenotic strictures) or too frequently (for diseases that would respond to less-potent therapy), it is also often introduced too late in disease progression. Conventional drugs are the mainstay of current therapy for inflammatory bowel diseases, but drug type, timing, and context must be optimized to manage individual patients effectively.

Publication types

  • Review

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Algorithms
  • Anti-Inflammatory Agents / administration & dosage
  • Anti-Inflammatory Agents / therapeutic use*
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Colitis / drug therapy
  • Colitis, Ulcerative / drug therapy*
  • Colitis, Ulcerative / physiopathology
  • Crohn Disease / drug therapy*
  • Crohn Disease / physiopathology
  • Disease Progression
  • Dose-Response Relationship, Drug
  • Drug Administration Schedule
  • Humans
  • Mesalamine / therapeutic use
  • Proctitis / drug therapy
  • Remission Induction
  • Severity of Illness Index
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors


  • Adrenal Cortex Hormones
  • Anti-Inflammatory Agents
  • Anti-Inflammatory Agents, Non-Steroidal
  • Tumor Necrosis Factor-alpha
  • Mesalamine