ReviewAnnals of gastroenterology
Is top-down therapy a more effective alternative to conventional step-up therapy for Crohn's disease?
Review in Annals of gastroenterology. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 34 papers, 3 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
34 citing papers in PubMed, 3 syntheses or guidelines pooled it, 52 citations in OpenAlex.
- Prognostic tools for identification of high risk in people with Crohn's disease: systematic review and cost-effectiveness study.Health technology assessment (Winchester, England) · 2021Pooled it
- Adalimumab for maintenance of remission in Crohn's disease.The Cochrane database of systematic reviews · 2020Pooled it
- Efficacy of early biologic therapy versus late/conventional therapy in children and adolescents with Crohn's disease: A systematic review and meta-analysis.Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology AssociationPooled it
- Optimizing Crohn's Disease Management in the Biologic Era-Insights from Real-World Evidence in Japan.JMA journal · 2026Article
- Long-Term Outcomes and Therapeutic Strategies for Newly Diagnosed Crohn's Disease in the Biologic Era: A Nationwide Claims-Based Study from Japan.JMA journal · 2026Article
- Real-world use of biologics during the first year of treatment for newly diagnosed Crohn's disease in Japan: a claims analysis from 2010 to 2021.Intestinal research · 2026Article
- Global Variability in the Management of Inflammatory Bowel Disease: Towards Context-Specific Strategies.Cureus · 2025Review
- Temporal trends in surgical treatment of inflammatory bowel disease following introduction of biological drugs in Norway and Sweden.BMJ open gastroenterology · 2025Article
- Management of Anal Fistula with Crohn's Disease.Journal of the anus, rectum and colon · 2025Review
- Health-care resource use and costs associated with inflammatory bowel disease in northwest London: a retrospective linked database study.BMC gastroenterology · 2024Article
- Sirolimus Use in Refractory Crohn's Disease.ACG case reports journal · 2024Article
- Inflammatory bowel disease: recent developments.Archives of disease in childhood · 2024Review
- Clinical Presentation and Outcome of Critically Ill Patients with Inflammatory Bowel Disease.Visceral medicine · 2024Article
- Trends in Medical Management of Moderately to Severely Active Ulcerative Colitis: A Nationwide Retrospective Analysis.Inflammatory bowel diseases · 2023Article
- Ileocecal valve that cannot be intubated in Crohn's disease: is this a sign of poor prognosis?International journal of colorectal disease · 2023Article
- Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease.Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association · 2022Article
- Prognostic Factors of Biologic Therapy in Pediatric IBD.Children (Basel, Switzerland) · 2022Article
- Under the Umbrella of Clinical Pharmacology: Inflammatory Bowel Disease, Infliximab and Adalimumab, and a Bridge to an Era of Biosimilars.Pharmaceutics · 2022Review
- Real-world utilization of top-down and step-up therapy and initial costs in Crohn disease.Journal of managed care & specialty pharmacy · 2022Article
- Indicators of Suboptimal Treatment and Associated Healthcare Costs Among Patients With Crohn's Disease Initiated on Biologic or Conventional Agents.Crohn's & colitis 360 · 2022Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
2 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
The management of Crohn's disease involves immunosuppressive protocols in a step-up approach that progresses through a therapeutic pyramid with several tiers of medication. Medications at the top are considered more potent but present greater risk. A new top-down approach to therapy inverts this procedure, using top-tier drugs for initial treatment. A critical appraisal of the current literature relating to top-down therapy was performed to evaluate its merit. A literature search was conducted on PubMed, Ovid, and PubMed Central to identify studies of the efficacy of top-down therapy. Papers were appraised critically using the Scottish Intercollegiate Guidelines Network score to evaluate current evidence for the use of top-down therapy. Nineteen studies were identified, including six randomized controlled trials, thirteen cohort studies, and two cost-benefit studies. Early combined therapy involving both biologics and immunomodulators was found to be effective at improving patient outcomes; however, early biologics alone were not shown to have a clear benefit over step-up therapy. Likewise, the early use of immunomodulators alone showed inconsistent results with respect to efficacy in terms of both remission and surgical outcomes. Evidence for application in pediatric populations was also inconclusive. The cost-benefit analyses found that top-down therapy merits investigation, as it proved to be economical given current data. Top-down therapy has the potential of being a viable alternative to step-up therapy, but further studies are needed to determine the most appropriate patients to receive this treatment.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.