Immunosuppression in inflammatory bowel disease: traditional, biological or both?

To focus on the emerging clinical evidence for the use of traditional immunosuppressives and biologicals in the treatment of inflammatory bowel disease.Evidence published this year indicates that in Crohn's disease the early use of combined infliximab and purine analogues before the introduction of steroid therapy induces faster steroid-free remission and improves mucosal healing. We have also learned that, in patients with Crohn's disease who are naïve to traditional immunosuppressive therapy, combined infliximab and azathioprine improves clinical and mucosal healing outcomes at 6 months. On the contrary, in patients already exposed to traditional immunosuppressives prior to starting infliximab, withdrawal of azathioprine or methotrexate after 6 months of combined scheduled infliximab maintenance with these agents does not affect outcomes after 2 years of continued infliximab therapy. Finally, several important studies on the safety of immunosuppressives including anti-tumour necrosis factor agents have been published. The cumulative body of evidence suggests that combined immunosuppressive therapy in patients with inflammatory bowel disease increases toxicity.Treatment paradigms for traditional immunosuppressives and biologicals in inflammatory bowel disease are evolving, and the choice of therapy becomes highly dependent on the drugs previously used and disease severity.