Preparing the patient for immunosuppressive therapy.

The decision to start immunosuppressive therapy comes with benefits and risks. Patient selection is as important as medication selection, because some patients are not appropriate for certain therapies. The decision is based on many factors, including diagnosis, level of disease activity, comorbidities, and sometimes socioeconomic status. Frank discussion about side effects, possible adverse events (different from side effects), and monitoring protocols needs to occur after the clinician has decided on a therapy. Some therapies require additional screening prior to initiation (eg, tuberculosis testing before initiating biologics). Steroids are aggressive treatment, but need to have an end point. Thiopurines need to be monitored routinely with blood tests, and are associated with short-term side effects that can lead to discontinuation in about 20% of patients. Methotrexate is perhaps underused by community practitioners despite an adequate evidence base for its use for active inflammatory disease. Methotrexate may also be helpful in patients with arthralgias, but must be monitored. Biologics now target two molecules (tumor necrosis factor [TNF]-α and TNF-α4 integrins). However, because anti-adhesion molecule therapy is associated with a lethal central nervous system infection estimated to occur in 1 of 1,000 patients, this approach tends to be used as a third- or fourth-line therapy. Anti-TNFs are used for Crohn's disease and ulcerative colitis with good results; however, immune reactions, infections, and neoplasms have resulted from their use.