Approach to treating IBD

Inflammatory Bowel Disease (IBD) are chronic diseases.  This means that people with IBD often need to take medications daily, weekly, monthly, or every few months in order to keep the disease under control.  Most common approaches to treating IBD are the “step up approach” and the “top down approach” although many treatment approaches are in between.


If you have IBD, your physician and health care team will help you through the management of your IBD.  Here, we briefly go over general approach to managing IBD.  Speak with your physician and health care team to learn more about your treatments.


“step up approach”

In this approach, the IBD is first treated with non-immunosuppressive agents (e.g. 5-aminosalicylate) and then “stepped up” to immunosuppressants (e.g. thiopurines, methotrexate) and/or biologics if the non-immunosuppressive agents fail, or if their disease is too severe for non-immunosuppressive agents.

  • What are 5-aminosalicylates (5-ASA) agents?
    • these are mesalamine containing compounds, with very few side effects
    • e.g. Asacol, Mesavant, Pentasa, Salofalk
    • they can be taken orally once to several times a day
    • there are topical forms (liquids, foams, suppositories that melt) which were made to coat the inner lining of the rectum and last part of the colon
      • the topical therapies may help with healing of the rectum (and help with the symptoms of urgency, rectal bleeding)
  • What are Immunosuppressants?
    • these are medications designed to suppress or modify the immune system
    • thiopurines (e.g. azathioprine (Imuran), 6-mercaptopurine (Purinethol)
    • methotrexate (must STOP BEFORE attempting to become pregnant)
    • steroids (e.g. prednisone, budesonide)
  • What are Biologics?
    • these are medications that were designed to specifically target a protein or a pathway of the inflammatory and immune responses
    • currently the approved biologics include antibodies (proteins that bind to other proteins) that block certain inflammatory pathways that are thought to lead to IBD
      • anti-tumour necrosis factor-alpha (anti TNF-a)
        • inflixmab (Remicade, Inflectra), adalimumab (Humira), golimumab (Simponi)
      • anti-interleukin (anti IL12/23)
        • ustekinumab (Stelara)
      • anti-integrin (anti-a4b7 )
        • vedolizumab (Entyvio)
    • these are given by intravenous infusions (IV), subcutaneous (just under the skin) injections (SC), or a combination of IV and SC


“top down approach”

In the “top down approach” the IBD is treated with immunosuppressants and/or biologics earlier or as the first medication used.  Clinicians have been moving towards this approach as research studies have shown that getting control of the IBD earlier in the disease course can lead to better outcomes, likely due to preventing complications of IBD from happening (e.g. fistulas, malnutrition, colectomy).

Click here for more information on IBD medications and pregnancy.



Surgery should be discussed at any stage in the “step up approach” or “top down approach”.  Surgery should not be considered a “failure of treatment” – as in many cases, surgery may be the best option for the person.  IN some cases, medications may be started “too late” in the disease course, after complications (e.g. strictures) have already developed – in these cases, surgery AND medications together may be the best option

For further information on different types of IBD surgeries, click here.

Click here for more information on IBD surgeries and pregnancy.


Clinical Trials

Clinical trials offer new therapies for patients with IBD

  • they can be existing medications (in various doses or forms)
  • new medications that target different proteins or pathways
  • new combinations of medications
  • new strategies of treatment are being studies

If you are planning to become pregnant in the near future, and are in a clinical trial, you should inform your physician and the research coordinator.   As you cannot become pregnant while participating in a clinical trial of medications.