Efficacy of combination therapy with anti-tumor necrosis factor and immunomodulators in inflammatory bowel disease

Jesús K. Yamamoto-Furusho , Inflammatory Bowel Disease Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, D.F., Mexico
Andrea Sarmiento-Aguilar, Inflammatory Bowel Disease Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

It has been shown that different approaches to the classic therapeutic pyramid for inflammatory bowel disease have different effects in clinical outcome. The early top-down strategy is nowadays the subject of diverse different studies and some controversy as it has been shown that the combination of immunomodulators and anti-tumor necrosis factors appears to be more efficacious than either therapy
alone, but may also confer an increased risk of infection and malignancy. When to introduce the combined treatment, which patients would benefit from this decision, and the optimal dose of each agent when used in combination is not clear yet. Nevertheless, we do have several studies that help us, to the extent possible, make the best decision for each individual case. Here, we discuss and analyze widely the up to date evidence on the efficacy of combined treatment. We consider that taking into account the studies we have so far, combination of infliximab and azathioprine is more effective than either as monotherapy, especially in early diagnosed patients, as it is proposed in the top-down approach to the therapeutic pyramid. The fear of adverse effects originating from this approach should not stop us from using combined therapywh en the individual case seems suitable for it.

Palabras clave: Combined treatment. Inflammatory bowel disease. Anti-TNF. Thiopurine.