Anti-TNF therapy in inflammatory bowel diseases

The introduction in the mid-1990s of anti- TNF-α agents changed the treatment of inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis refractory to conventional medications (corticosteroids, immunomodulators). This review summarizes current data on efficacy, safety and indications of anti-TNF therapy in IBD, and discusses future directions for these agents in IBD. We searched Medline, the Cochrane Library and Embase for relevant studies. Infliximab, adalimumab and certolizumab are more effective than placebo for induction and maintenance of remission in luminal Crohn's disease. Infliximab is effective for maintenance of fistula closure in Crohn's disease, and adalimumab is also likely to have this activity. Only infliximab is approved by the US Food and Drug Administration for ulcerative colitis. Only adalimumab has demonstrated its efficacy to induce remission after infliximab failure in Crohn's disease in a randomized controlled trial. Anti-TNF therapy leads to mucosal healing, reduces hospitalizations and surgeries, and improves patients' quality of life. Safety data indicate that serious infections occur in 2-4% of patients treated with anti-TNF therapy, with no statistical difference when compared to controls. The risk of rare events, such as malignancies and lymphoma, in IBD patients treated with anti-TNF agents, requires a longer duration of follow-up. It is concluded that currently, the risk-benefit ratio of anti-TNF therapy supports its use in IBD. Several questions remain to be answered: are TNF antagonists truly disease-modifying agents, should mucosal healing be used in clinical practice, and should anti-TNF therapy be used alone or in combination with immunomodulators in the long term?