Clearing of the Clouds in Inflammatory Bowel Disease Management
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PERSPECTIVE
Clearing of the Clouds in Inflammatory Bowel Disease Management Nicholas V. Costrini1 Received: 4 June 2020 / Accepted: 22 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The skies over inflammatory bowel disease care are beginning to clear. Success is being achieved in the management of inflammatory bowel disease due to ongoing research, new medications, and most significantly to the recognition of the importance of patient selection and the definition of remission. Five answered questions provide the basis for recent successes and forecast for clearing of the clouds. How do we classify the inflammatory bowel disease (IBD) patient? How do we select our medications to best match the patients’ classifications? How do we monitor and manage medications during the course of care? How can we predict the likelihood of response to a selected medication? Besides medications and surgery, what else is needed for best care in 2020 and beyond? These questions are addressed in this communication. Keywords Inflammatory bowel disease · IBD classification · IBD diagnosis · IBD management · Crohn’s disease · Ulcerative colitis
Introduction For the past 20 years, the skies over inflammatory bowel disease (IBD) care have been partly cloudy. In the prior century, chronic ulcerative colitis (UC) and Crohn’s disease (CD) were managed with a few marginally successful medications. The new century greeted us with significant advances in our still incomplete understanding of the complex pathogenesis of IBD [1, 2] and with the introduction of infliximab [3]. Although we have certainly not yet defined “the cause” of IBD, four factors are currently considered to be most prominent in the initiation and chronicity of IBD. These are: genetics [4], the environment [5], the gut microbiome [6], and pro-inflammatory immunologic dysregulation [2]. Our current understanding and the ongoing research in these arenas are richly reported in the above-listed references. These areas of research are of keen interest not only for their intellectual challenges but also for the direction they may supply for the pragmatic need to develop efficacious therapies. Such has been the case with the development of the infliximab, the monoclonal antibody antagonist to the pro-inflammatory cytokine tumor necrosis factor (TNF-α) * Nicholas V. Costrini [email protected] 1
Florida State University College of Medicine, Tallahassee, FL, USA
and for the host of additional therapeutics now available and soon coming online for the management of IBD. One would have thought that the arrival of this first inflammatory bowel disease (IBD) biologic therapy would have been the best news ever. Well, that happy gospel didn’t sustain us for very long. With the entry of other anti-TNF-α agents, the first two decades have proved less productive than anticipated. Perhaps one in four patients with IBD experienced long-term benefit from our host of anti-inflammatory ammunition. We missed the correct recognition of what constitute
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