Report: pharmacotherapy for moderate to severe inflammatory bowel disease: evolving strategies

Moderate to severe disease causes substantial morbidity in inflammatory bowel disease (IBD). The approach to pharmacotherapy for patients with moderate to severe ulcerative colitis and Crohn's disease is undergoing a fundamental transformation to change the course of disease in these patients. Disease severity is being redefined to consider the impact on the patient, its inflammatory burden, and the disease course. Prevention of disease progression and complications are replacing symptomatic remission as the goal of therapy. To achieve these goals, the treatment approach is evolving from a stepwise to a treat-to-target approach, with patients stratified to treatment according to their risk of disease progression or complications. The primary drug classes for induction and maintenance of remission in moderate to severe IBD are corticosteroids, thiopurines, tumor necrosis factor antagonists, and vedolizumab. Use of these drug classes is changing as IBD management evolves. This article reviews the efficacy, adverse effects, drug interactions, and special issues for each class. The role for each class is formulated based on results of key clinical trials and meta-analyses, as well as clinical practice guideline recommendations.