Future therapy for inflammatory bowel disease: should we rethink what we mean by “Top Down”?

Farthing, Michael J G (2007) Future therapy for inflammatory bowel disease: should we rethink what we mean by “Top Down”? Current Gastroenterology Reports, 9 (5). pp. 355-357. ISSN 1522-8037

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Conventional wisdom in both the science and art of the practice of medicine for several centuries has followed the principle that there is a hierarchical approach to treatment that begins with the least potent medication. If this fails, then the clinician recommends a more potent remedy, and so on until the symptoms are controlled; the approach therefore is one of “therapeutic escalation.” Factors such as risk and cost, as well as potency, might also be included in the decisionmaking process to establish the therapeutic hierarchy. For many conditions this approach is still entirely appropriate. It is particularly relevant for a symptom such as nonspecific headache, which is extremely common, a condition in which the etiology is far from certain and for which at present there is no lasting cure. The same pertains for the diverse symptom consortium of the irritable bowel syndrome. The approach to therapy remains directed by the severity and the nature of the predominant symptom; the intervention option is selected on this basis. However, when the etiology of a condition is known or partly understood and when treatments are available that can or might alter the natural history of the disease, then it may be appropriate to use a more potent agent earlier in the patient’s journey. It will of course be necessary to consider additional factors such as the frequency of serious unwanted effects of more potent medication and the cost-benefit analysis. This approach is now commonly used in most cancers, in HIV infection, and viral hepatitis and increasingly in rheumatoid arthritis, in which a number of agents have been clearly shown to modify disease.

Item Type: Article
Schools and Departments: Brighton and Sussex Medical School > Clinical and Experimental Medicine
Depositing User: Adam Tickell
Date Deposited: 07 Feb 2012 15:51
Last Modified: 31 Jul 2012 07:53
URI: http://sro.sussex.ac.uk/id/eprint/36016
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