Crohn's disease therapy: step up or top down therapy

In most Crohn's disease scenarios a step-up approach has been used to initiate therapy according to disease severity. However, this approach has ignored the concept of inductive therapy followed by maintenance treatment to prevent relapse. It is apparent from clinical trials that the success of maintenance approaches will depend upon the inductive therapy. Furthermore, the step-up approach often results in steroid-dependent or refractory disease. The potential of aggressive initial therapy followed by step-down maintenance therapy affords the potential to modify the disease course, a possibility that has not been accomplished by current therapeutic algorithims.