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

journal contribution
posted on 2023-06-08, 10:11 authored by Michael J G Farthing
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.

History

Publication status

  • Published

Journal

Current Gastroenterology Reports

ISSN

1522-8037

Publisher

Springer Verlag

Issue

5

Volume

9

Page range

355-357

Department affiliated with

  • Clinical and Experimental Medicine Publications

Full text available

  • No

Peer reviewed?

  • Yes

Legacy Posted Date

2012-02-07

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