Immunosuppression in inflammatory bowel disease: how much is too much?

Current treatment approaches favor the early introduction of immunomodulators and/or antitumor necrosis factor (TNF) agents. There is now strong evidence showing that combination therapy appears to be more effective than monotherapy in both ulcerative colitis and Crohn's disease. However, there are concerns associated with this strategy, and eventually the following questions will emerge when discussing therapeutic options with our patients: is it safe to maintain these therapies for the long-term?; how long should we maintain therapy?; and if we decide to stop or de-escalate therapy, what strategy should we use?

During the past year new evidence regarding safety of long-term therapy with anti-TNF and immunomodulators, and predictors of relapse following therapy discontinuation have become available.

In this review we aim to discuss some of the safety concerns related to the use of immunosuppressive drugs used in inflammatory bowel disease, as well as the possible strategy for de-escalation or discontinuation therapy. Eventually, choosing to stop either the anti-TNF or the immunomodulator is a case-by-case decision based on the estimated risk-benefit ratio. In addition to the identified predictors of relapse after therapy discontinuation, other considerations such as long-term safety, cost, and natural history of the disease must be brought into this discussion.