Oldenburg Bas, Hommes Daan
Department of Gastroenterology, University Medical Center Utrecht, The Netherlands.
Curr Opin Gastroenterol. 2007 Jul;23(4):395-9. doi: 10.1097/MOG.0b013e32815b601b.
Conventional therapeutic algorithms cannot, or only to a certain degree, prevent surgery or complications in inflammatory bowel disease. The new concept of early aggressive or 'top-down' treatment has evolved from the impressive results of new biological agents in the treatment of patients who were refractory to standard therapy. New data, suggesting that this strategy may be advantageous, has recently been published.
In uncontrolled studies, early administration of azathioprine as well as infliximab has been shown to be associated with a prolonged maintenance of remission in Crohn's disease patients. The recently presented preliminary data from a controlled study comparing early administration of infliximab and azathioprine ('top-down' therapy) versus conventional 'step-up' therapy showed superior mucosal healing, a more rapid remission and higher remission rates in patients in the top-down treatment arm. The ongoing SONIC study, which compares infliximab therapy with and without azathioprine, will provide additional information regarding the relative importance of both drugs in this respect.
The significance of top-down treatment remains to be confirmed in prospective clinical studies aimed at high-risk patients. The standard use of this approach cannot be advocated presently.
传统治疗方案无法完全预防炎症性肠病的手术治疗或并发症，或仅能在一定程度上预防。早期积极或“自上而下”治疗的新概念源于新型生物制剂在治疗对标准疗法耐药患者时取得的显著疗效。近期发表了新数据，表明该策略可能具有优势。
在非对照研究中，早期使用硫唑嘌呤以及英夫利昔单抗已被证明与克罗恩病患者的缓解期延长有关。近期一项对照研究给出的初步数据比较了早期使用英夫利昔单抗和硫唑嘌呤（“自上而下”疗法）与传统“逐步升级”疗法，结果显示“自上而下”治疗组患者的黏膜愈合情况更佳、缓解更快且缓解率更高。正在进行的SONIC研究比较了使用和不使用硫唑嘌呤的英夫利昔单抗治疗，将提供关于这两种药物在这方面相对重要性的更多信息。
“自上而下”治疗的重要性仍有待在前瞻性临床研究中针对高危患者加以证实。目前尚不能提倡该方法的常规使用。
