How should immunomodulators be optimized when used as combination therapy with anti-tumor necrosis factor agents in the management of inflammatory bowel disease?

Core Tip

Core tip: Clinicians managing inflammatory bowel disease frequently have to decide whether to use anti-tumor necrosis factor (anti-TNF) therapy alone or in combination with immunomodulators (IM), which requires an assessment of patient factors and the risk/benefit profile of each treatment strategy. Once a decision is made to use combination therapy, questions on how best to optimize IMs must be addressed. Thiopurines, rather than methotrexate, (MTX) are more efficacious and easier to administer, whereas in certain population groups, MTX may be safer. The effective dose of IM may be lower in combination therapy and combination therapy is probably most important in the first 12 mo of treatment. Withdrawing IMs is best done when the patient is in deep remission, ideally supported by the use of therapeutic drug monitoring of anti-TNFs.