Volume 7 Issue 2, February 2010

The characteristics of functional heartburn remain poorly understood. Savarino et al. have now demonstrated that functional heartburn has more in common with functional dyspepsia than with nonerosive reflux disease. This study suggests that there is substantial overlap between functional heartburn and functional dyspepsia, and possibly that these two disorders may actually be one functional esophagogastric disorder.

The role of total pancreatectomy for pancreatic adenocarcinoma is controversial. Concerns have been raised about increased morbidity and mortality, and poorer long-term outcomes associated with total pancreatectomy compared with pancreaticoduodenectomy. Reddy and colleagues recently reported data that support the use of total pancreatectomy, when appropriate, in clinical practice.

Ursodeoxycholic acid (UDCA) is widely used for the treatment of chronic cholestatic liver diseases. However, a recent randomized, controlled trial has surprisingly shown that the use of high-dose UDCA in patients with primary sclerosing cholangitis (PSC) may be harmful; adverse events, such as death and liver transplantation, were significantly higher in patients who received UDCA compared with placebo.

The first prospective, double-blind, randomized controlled study of acetylcysteine for the treatment of patients with non-acetaminophen-induced acute liver failure supports its use in patients in the early stages of liver failure. Emergency liver transplantation still has a fundamental role in the management of patients with the most severe form of this syndrome.

Some patients who have diverticular disease develop complications or recurrent symptoms and medical therapy may be necessary. Findings from recent studies suggest that rifaximin, a poorly absorbed antibiotic, should be recommended for long-term treatment of diverticular disease; however, the anti-inflammatory drug mesalazine seems to be more promising in the long term.

Treatment of patients with Crohn's disease to delay the natural evolution of the disease and avoid the development of complicated disease as well as the need for hospitalization and surgery is desirable. Gert Van Assche and colleagues discuss the disease-modifying potential of immunosuppressive and anti-tumor necrosis factor therapies, especially when given as early, aggressive therapy.

Early treatment of Crohn's disease with immunomodulators and anti-TNF agents is associated with better clinical outcomes than standard therapy, but these drugs may have serious adverse effects and are not suitable for all patients. The author reviews current clinical evidence and proposes a strategy for adequate selection of patients for top-down therapy of IBD.

Despite the widespread use of biologic therapy for IBD, safety concerns still exist. To realize the full potential of these therapies it is important to select appropriate patients for therapy and to optimize the delivery of these agents, thus maximizing their effectiveness. At the same time it is important to adopt strategies before and during treatment that minimize the occurrence of adverse effects. This Review outlines the adverse events associated with biologic therapies, and gives recommendations on how to reduce the risk of these events.

IBD is associated with a young age at onset and normal life expectancy, which results in a lifetime accrual of disease-related costs. This Review discusses the economic impact of biologic therapy on direct costs of IBD, such as hospitalizations and surgeries, and indirect costs, such as those related to disability and loss of productivity.

IBD treatment has evolved towards biologic therapy, which seeks to target specific immune and biochemical abnormalities at the molecular and cellular level. Improved understanding of the pathogenesis of IBD has suggested future drug biologic targets, which are currently being investigated. This Review article discusses the potentials and pitfalls of biologic therapy for IBD as this field advances at a rapid pace.

In this Focus issue, leaders in the field provide an update on the current status of biologic therapies for IBD and set the stage for developments in the near and distant future. Encompassing discussion of the potential for disease modification, therapeutic rationale and requisite evidence, safety, pharmacoeconomics, and future targets, this Focus provides a valuable and cutting-edge resource for clinicians and researchers.