Immunosuppressants and immune modulators in luminal gastroenterology

Heritage small molecule immunosuppressants and the immune-acting biologics have a major place in the management of luminal gastrointestinal disease and especially so in inflammatory bowel disease. This narrative review considers their current use, concentrating on issues not already well addressed in the literature. An evidence-based approach is taken, supplemented by advice based on observations from clinical practice when data are missing. There is a general trend towards earlier use of the biologics for perceived greater safety and impact on disease modification, despite their substantially greater cost and systemic administration. Early semi-prophylactic treatment is now considered for patients with high-risk Crohn's disease. In other conditions the immune active agents remain a back-up for those failing to respond to simpler options. There are few and mostly unimportant differences between the different antibodies to TNFα, but it is beginning to be possible to identify patients who could be preferentially treated with an anti-integrin approach or by addressing other cytokines.