A review of current evidence allied to step-up and top-down medication therapy in inflammatory bowel disease

Drugs Today (Barc). 2019 Jun;55(6):385-405. doi: 10.1358/dot.2019.55.6.2969816.


Inflammatory bowel disease (IBD), classified as a global disease in the 21st century, comprises Crohn's disease (CD) and ulcerative colitis (UC), and is manifested by chronic inflammation of the gastrointestinal tract of unknown etiology. The step-up approach is effective for inducing remission and controlling inflammation, whereas the top-down therapy appears to be a better solution for the maintenance of remission with an improved bowel function. A systematic search was performed in Ovid MEDLINE and Embase (1946-December 2018) to identify relevant trials that support medication therapy in IBD. Thirty-nine potential trials were retrieved, of which 29 focused on CD, and 10 studied UC. There is mounting evidence on both benefits and disadvantages in the application of early initiation of top-down therapy in suitably selected patients. Nevertheless, there are uncertainties about the appropriateness of these approaches for the management of IBD and there are conflicting results in overall outcomes including mucosal healing and rehospitalization. The choice of either top-down or step-up therapy in the treatment of IBD should be an individualized approach and cannot be recommended as a part of a generalized guideline. Further prospective studies are warranted to determine whether combination therapy or aggressive therapy is superior to monotherapy.

Keywords: Crohn's disease; Gastrointestinal disorders; Inflammatory bowel disease; Step-up therapy; Top-down therapy; Ulcerative colitis.

Publication types

  • Systematic Review

MeSH terms

  • Colitis, Ulcerative / drug therapy
  • Combined Modality Therapy
  • Crohn Disease / drug therapy
  • Humans
  • Inflammatory Bowel Diseases / drug therapy*