Egyptian Perspectives in Tailoring Treatment Regimens for Patients With Inflammatory Bowel Disease: Step-Up Vs. Top-Down Approaches Survey
Authors: Negm Mohamed , ElGamal Rawan , Rizk Mario , Shawky Ranin , Cordie Ahmed 
Published: January 2023

The prevalence of Inflammatory bowel disease has been rising worldwide causing significant health and economic burden. Treatment strategies in patients with IBD involve multiple pharmacological and surgical interventions and are based on disease severity, location of lesions, response to medications and co-morbidities.
The conventional treatment strategy for patients with IBD, namely “step-up” approach, involves initial therapy with amino salicylates and corticosteroids, followed by immunomodulators such as azathioprine and 6-mercaptopurine, then escalation to biological therapies as infliximab.
This step-up approach progresses through a therapeutic pyramid, considering medications at the top being more potent but posing more risk for adverse events or considered expensive.
The alternative treatment approach, referred to as “top-down” approach, involves the use of more potent drugs early in patient care to control disease progression and improve outcomes. Patients with active Crohn's disease benefit more from top-down approach than step-up approach.
Aim:
To evaluate the knowledge and compliance of physicians involved in management of patients with inflammatory bowel disease with the concept of “step-up vs. top-down” approaches in management of those patients. And, how they base their decisions when tailoring treatment regimens for their patients.
Methodology:
A self-administered questionnaire, designed according to European and US guidelines, using ten direct questions aiming at assessing Egyptian physicians who deal with patients with inflammatory bowel disease for their knowledge, background, site of practice, medication availability as well as the number of patients with inflammatory bowel disease they encounter. Also, the factors that control how they base their choice of treatment.
Results:
Two hundred and ten questionnaires were received out of the 300 distributed by email. Most of respondents work in University Hospitals. Approximately, 41% respondents reported that they encounter less than 5 patients every month. Around 29% of respondents noted that they have more than two biological therapies in their health care facility and 26% have only 2 types.
Majority of respondents (84%) were familiar with the concept of step-up vs. step-down approaches.
More than 50% of participants mentioned that they never start with biological therapy in moderate disease.
Around 60% of respondents believe that biological therapy should be given only to patients who failed conventional therapy with steroids with/without immune modulators, with severe complications or extraintestinal manifestations. Eighteen percent noted that it depends on the availability.
Conclusion:
Step up and Top-down approaches are well known to most physicians who deal with inflammatory bowel disease patients. Yet not everyone complies with those concepts. The most important causes for this are the old concepts of preserving biological therapy for patients who failed conventional therapy regardless of disease severity or complications. Also, availability and cost play a very important role in physicians’ choice.