Treatment of mild to moderate IBD still follows a traditional step-up approach and is typically started with aminosalicylates that are more effective in UC than CD, for which efficacy data are limited. Several medications of this class are commercially available – mesalamine, balsalazide, and sulfasalazine with similar efficacy and safety profiles. Those patients who fails to respond to aminosalicylates are switched to corticosteroids – oral prednisone at a dose of 10-40 mg/day with a potential to increase the dose up to 60 mg/day or use of intravenous (IV) corticosteroids in more refractory cases [15]. Immune-modifying agents (infliximab, adalimumab, and vedolizumab) are used if corticosteroids fail or are required for prolonged periods. Generally speaking, if the patient requires therapy beyond step 1 (aminosalicylates), the goal is to wean the patient off steroids as soon as possible to prevent steroid-mediated long-term adverse effects.
There are 4 well recognized international guidelines on IBD treatment: World Gastroenterology Organization Global Guidelines on the IBD [11], Consensus guidelines on the management of inflammatory bowel disease from the British Society of Gastroenterology [16], the Guidelines on the medical and surgical management of Crohn disease from the European Crohn's and Colitis Organization (ECCO) [17], and the Clinical Practice Guidance on the medical management of adult patients with moderate to severe ulcerative colitis (UC) from the American Gastroenterological Association (AGA) [18].