Step-up vs. top-down approach in medical management of inflammatory bowel disease

Abstract

In recent years, the medical care for patients suffering from Crohn's disease (CD) has changed considerably. Nowadays clinicians are equipped with a robust set of tools, supported by a substantial body of literature, on how to act upon diagnosing CD for the first time. There seems general consensus on the diagnostic process, using a full endoscopic workup in combination with radiologic and histopathologic assessments [1]. Once diagnosed, it is up to the team of IBD health professionals to fully inform and educate the patient and his/her relatives, and to install and monitor a vigorous medical regime. The main treatment goals are (1) to achieve clinical remission of steroids as soon as possible, (2) to achieve endoscopic remission, (3) to avoid hospitalization and surgery, and (4) to improve the quality of life. Indeed, today we are able to monitor the success of each of the treatment goals very ffectively: (1) monitoring the rate of clinical remission in daily practice can be performed on a week-to-week basis by, for example, a specialized IBD nurse, using well-defined and validated parameters of general well-being, abdominal pain, stool frequency, extra intestinal manifestations, and general symptoms like fever and weight. More and more, IBD centers are establishing remote care delivery systems for monitoring disease activity indices on a regular basis and thus partly allowing self-management [2]. Next to clinical parameters, a defined set of laboratory values like CRP is recommended nowadays for monitoring. In addition, most steroid tapering schedules can be completed within 8 weeks. Intervention is required much sooner than 8 weeks should patients continue to have active disease. (2) the paradigm of mucosal healing has been well accepted upon publication of a large number of studies showing the relevance of endoscopic assessments for the prediction of clinical remission [3– 5]. Alternative biomarkers for mucosal healing are under development since endoscopy remains an invasive procedure, for instance, fecal calprotectin and fecal lactoferrin [6– 8]. Again, these fecal tests could also be very well for home monitoring of mucosal healing. (3) it has also been shown that induction of clinical and endoscopic remission decreases the number of hospitalizations and surgeries in CD patients [9]. (4) Similar to clinical remission, the quality of life of CD patients dramatically improves upon reaching the previously discussed treatment goals [4, 10, 11].