Optimizing the use of tumour necrosis factor inhibitors in Crohn's disease: a practical approach

Crohn's disease is a chronic, disabling, inflammatory condition of the gastrointestinal tract that has a segmental distribution and can affect the entire gastrointestinal tract. Treatment of patients with Crohn's disease represents a difficult challenge to physicians. Conventional therapy includes corticosteroids and immunosuppressants. Corticosteroids are highly effective for inducing response and remission, but the results in the long-term are disappointing and are associated with serious adverse events. Immunosuppressants are effective, but have a slow onset of action and are associated with intolerance and adverse events. In the last decade, as a result of a better understanding of the immunopathology of inflammatory bowel disease, novel therapeutic agents have been developed to target crucial components of the inflammatory cascade. Tumour necrosis factor (TNF) inhibitors (infliximab, adalimumab and certolizumab pegol) offer an effective alternative therapy, and are widely used in clinical practice for the management of Crohn's disease and ulcerative colitis. This article focuses on the latest evidence-based data on clinical effectiveness, mucosal healing, immunogenicity, dose optimization for induction and maintenance of response and remission, and step-up versus top-down approaches of the available TNF inhibitors for the treatment of Crohn's disease.