152 153 Intestinal Disease Meeting Berlin 2006 - Dr. Falk Pharma ...

J. Schölmerich
Only a minority of patients profits
from the “Top Down” concept
Not in favor of this concept was J. Schölmerich
(Regensburg). In his opinion, the proponents of
the “Top Down” concept overlook the fact that
only a minority of patients do not benefit from
the currently standard “Step Up” paradigm. The
more aggressive “Top Down” approach would
represent an unnecessary risk for these patients
and also burden the medical insurance system
with unjustifiable increased costs. According to
J. Schölmerich, the goal of treatment of IBD consists
of reducing patients’ symptoms, inducing
and maintaining disease remission and thus preventing
renewed acute disease flares and structural
changes. “These objectives,” he said, “are
realized in the majority of patients using the
standard therapy.”
Start with medications of proven
efficacy
The “Step Up” model begins with medications
of proven efficacy, such as mesalazine in ulcerative
colitis and, in Crohn’s disease, of this medication
together with the locally acting steroid
budesonide and, where indicated, antibiotics.
Only when these medications do not prove effective,
said J. Schölmerich, should patients be
started on medications, such as systemic corticosteroids,
azathioprine or even methotrexate,
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that are stronger but also are associated with
greater risk of side effects. If patients fail to respond
to these medications with remission or if
they relapse the next step can be administration
of the TNF-α inhibitor infliximab or cyclosporine,
which is indicated in ulcerative colitis.
Very few patients require
accelerated therapy
This type of accelerated therapy is required in
only a small percentage of patients, the gastroenterologist
said. A majority of patients, in
fact, can be brought to remission during the first
therapy step and can be maintained free of disease
flares for extended periods. J. Schölmerich
cited data according to which 35% of Crohn’s
patients and 48% of those with ulcerative colitis
remain symptom-free and feel well at four years.
The fact that patients with inflammatory bowel
diseases exhibit a practically normal life expectancy
also confirms the success of the current standard
treatment in the majority of cases.
In addition, J. Schölmerich said, the exact meaning
for an individual patient of endoscopically
documented mucosal healing and whether this
observation is associated with a better long-term
outcome remains completely unclear. “Unlike in
rheumatology, where joint destruction can be
directly visualized, there are no corresponding
endpoints in inflammatory bowel diseases,”
J. Schölmerich said. At present, mucosal healing
can be considered a surrogate parameter, the
long-term meaning of which in achieving a favorable
disease course remains unclear. According
to J. Schölmerich, the current situation does
not justify treating patients with newly diagnosed
Crohn’s disease or ulcerative colitis according to
the “Top Down” model. This would, in his opinion,
represent “overtreatment”.
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