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  • Review Article
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First-line therapy in adult Crohn's disease: who should receive anti-TNF agents?

Nature Reviews Gastroenterology & Hepatology volume 10, pages 345–351 (2013)Cite this article

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Abstract

Therapy for Crohn's disease has long been based on a step-up approach, with monoclonal antibodies against TNF as a final option before surgery. Despite the introduction of these monoclonal antibodies, no major changes have occurred in the natural history of Crohn's disease, with half of all patients still requiring intestinal resection at 10 years. Labelling for anti-TNF agents does not take into account prognostic factors. In this Review, we propose that treatment of Crohn's disease be based on the following three disease stages: mild, moderate and severe. In patients with Crohn's disease who have complicated disease or bowel damage, and with poor prognostic factors and/or severe disease, anti-TNF treatment should be considered as first-line therapy. For patients living in areas of high risk of developing tuberculosis, as well as for patients with mild-to-moderate Crohn's disease without poor prognostic factors and with uncomplicated disease, steroids and thiopurine should be the first-line therapy. By treating patients with Crohn's disease in accordance with these disease stages, we might be able to alter disease course and reduce overtreatment. Upcoming disease-modification trials are expected to provide information to guide decision-making, ultimately changing the course of disease and improving patient quality of life.

Key Points

  • Anti-TNF therapy is the most potent drug class in Crohn's disease and has the potential for disease modification

  • TNF antagonists are underused or used too late in the course of Crohn's disease

  • In patients with Crohn's disease who have complicated disease or bowel damage, and with poor prognostic factors and/or severe disease, anti-TNF treatment should be considered as first-line therapy

  • Long-term benefit:risk ratio and cost-effectiveness ratio of therapeutic strategies (based on a wider and prolonged use) using anti-TNF therapy will require additional investigation

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Figure 1: Current approach for the treatment of Crohn's disease.
Figure 2: A proposed algorithm for the treatment of Crohn's disease.

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Change history

  • 16 April 2013

    In the version of this article initially published online, the section on first-line anti-TNF therapy should have noted that infliximab and adalimumab are both approved for moderately to severely active Crohn's disease. The error has been corrected for the print, HTML and PDF versions of the article.

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Acknowledgements

L. Peyrin-Biroulet and S. Danese shared senior authorship for this article.

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Authors and Affiliations

  1. U954 and Department of Hepato-Gastroenterology, INSERM, University Hospital of Nancy, Allee du Morvan, 54511, Vandoeuvre-l`s-Nancy, France

    Laurent Peyrin-Biroulet & Anthony Buisson

  2. Division of Gastroenterology, IBD Center, Humanitas Clinical and Research Center, Milan, 20089, Rozzano, Italy

    Gionata Fiorino & Silvio Danese

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  1. Laurent Peyrin-Biroulet
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  2. Gionata Fiorino
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Contributions

L. Peyrin-Biroulet, G. Fiorino, A. Buisson and S. Danese wrote the first draft of the manuscript. L. Peyrin-Biroulet and S. Danese made substantial contributions to discussion of content, and L. Peyrin-Biroulet reviewed/edited the manuscript before submission. L. Peyrin-Biroulet, G. Fiorino and A. Buisson researched data for the article.

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Correspondence to Silvio Danese.

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Competing interests

L. Peyrin-Biroulet has received consulting and/or lecture fees from Abbott, Bristol–Meyers Squibb, Ferring, Genentech, Merck, Mitsubishi, Norgine, Pharmacosmos, Pilège, Shire, Therakos, Tillots, UCB Pharma, Vifor. G. Fiorino has served as a speaker and as a consultant for Abbott Immunology and MSD. S. Danese has served as a speaker, consultant and is on the Advisory Board for Abbott Laboratories, Actelion, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Millenium Takeda, MSD, NovoNordisk, Nycomed, Schering–Plough, UCB Pharma. A. Buisson declares no competing interests.

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Peyrin-Biroulet, L., Fiorino, G., Buisson, A. et al. First-line therapy in adult Crohn's disease: who should receive anti-TNF agents?. Nat Rev Gastroenterol Hepatol 10, 345–351 (2013). https://doi.org/10.1038/nrgastro.2013.31

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