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Step-Up or Top-Down for Crohn’s Disease: Treatment Options

Medically Reviewed by Melinda Ratini, DO, MS on June 20, 2022

Crohn’s disease is difficult to treat successfully. Over time, most people who have it end up with serious complications like blockages or holes in the walls of their intestines.

The traditional medical treatment has been to start with the mildest drugs, and add stronger medicines as symptoms get worse. That’s called the “step-up” method.

But there’s a newer, opposite way. Doctors prescribe the most powerful drugs first in hopes of stopping the disease in its tracks. That’s called the “top-down” method.

Both methods have potential benefits and risks.

Step-Up Therapy for Crohn’s

The medications used in the step-up and top-down methods are the same. You’ll just get them in a different order.

The step-up method starts with aminosalicylates and works up through corticosteroids, immunomodulators, and biologics if your symptoms don’t get better or when you have relapses.

Aminosalicylates. These drugs may be used first if you have mild to moderate symptoms. They control inflammation in the intestinal tract, and work best if your colon is the part that’s mainly affected. You might take:

Corticosteroids. For moderate to severe Crohn’s disease, your doctor might start with steroid medicines. These calm the activity of your immune system. They do a good job of getting you into remission, which means you’ll show few to no symptoms. But generally steroids aren’t used long-term to keep you in remission, because they cause serious side effects. Choices include:

Top-Down Therapy for Crohn’s

The top-down method starts off the bat with immunomodulators, biologics, or a combination of both as soon as you’re diagnosed. If you don’t get results from these, your doctor might try less-potent corticosteroids or aminosalicylates.

Immunomodulators. These lower the activity of your immune system to reduce inflammation. In the top-down method, you might get them as soon as you’re diagnosed without first trying corticosteroids. These drugs include:

Biologics. These lower inflammation in a different way, by blocking the action of certain proteins in your immune system. They’re the last-resort drugs of the step-up method. Your doctor may prescribe them when other drugs haven’t worked. In the top-down method, you’d get them first. You might be prescribed:

While there’s no cure for Crohn’s, the goal of treatment is to get you into remission, then keep symptoms from coming back as long as possible.

What Are the Pros and Cons of Step-Up Crohn’s Therapy?

Very little research has been done to compare these approaches head-to-head. And the results have been mixed.

The main benefit of the step-up method is that it avoids over-treatment. You only get the minimum amount of medicine you need to get relief. More powerful medicines are available to you if the first ones don’t work, or if your disease gets worse.

Drawbacks with the step-up method include:

  • Less-powerful medicines may improve your symptoms, but they don’t do anything to repair the damage Crohn’s does in your intestines.
  • Most people who get the more traditional Crohn’s treatment end up with serious complications, including blockages and holes in their intestines that often need surgery.
  • Steroids don’t work for everyone. And if they do bring your disease into remission, you might not be able to stop taking them without your symptoms coming back.

What Are the Benefits and Drawbacks of Top-Down Crohn’s Therapy?

The top-down method can help you get into remission faster. You can also have fewer flare-ups. More importantly, immunomodulators and biologics can actually repair the damage Crohn’s disease does to your intestines. That means getting them sooner could change the way the disease normally progresses, and possibly prevent the most serious complications.

Drawbacks with the top-down method may include:

  • It’s hard to know whether a mild case of Crohn’s will become more serious. So you run the risk of taking stronger medicine than you need.
  • Biologics and immunomodulators are more expensive than other medicines. Your insurance company might not pay for them unless other methods don’t work.

What Are Other Risks From Crohn’s Treatment?

Some of the medicines used to treat Crohn’s have the potential for serious side effects. By lowering how well your immune system works, corticosteroids, immunosuppressants, and biologics all make you more likely to get a dangerous or even deadly infection. Other potential problems include:

Corticosteroids: There’s a long list of side effects these drugs can cause, which is why they aren’t recommended for use long-term. You might have:

Immunomodulators: Long-term, these drugs can increase your risk of certain cancers, including lymphoma and skin cancer. They can also cause:

Biologics: Often, these drugs stop working because your immune system learns to work against them. But that may be prevented by taking them in combination with an immunomodulator. You’re also more likely to have:

Which Crohn’s Treatment Approach Is Best?

To decide which approach is best for you, your doctor will look at any other health problems you might have, and whether your symptoms suggest you’re likely to get serious complications. The extent of your disease also makes a difference:

Mild. With mild disease, the less-powerful drugs used in the step-up method may be all you need. As many as half of people with Crohn’s never even need the more aggressive medicines.

Moderate. The top-down approach may help head off serious complications for people with moderate disease. It may also be best if you have a lot of flare-ups or trouble with steroids.

Severe. The top-down method is recommended for severe Crohn’s disease.

Show Sources

SOURCES:

Expert Review of Gastroenterology and Hepatology: “What is the optimal therapy for Crohn’s disease: Step-up or top-down?”

American Journal of Gastroenterology: “ACG Clinical Guideline: Management of Crohn's Disease in Adults.”

Crohn’s and Colitis Foundation: “What is Crohn's Disease?” “Step Therapy: An Obstacle Course to Optimal Health.”

Annals of Gastroenterology: “Is top-down therapy a more effective alternative to conventional step-up therapy for Crohn’s disease?”

National Institute of Diabetes and Digestive and Kidney Diseases: “Treatment for Crohn’s Disease.”

Digestive Diseases: “Medical Therapy for Crohn’s Disease: Top-Down or Step-Up?”

Gut: “Risks and benefits of biologic therapy for inflammatory bowel diseases.”

Practical Gastro: “A Practical Review on When and How to Select First-Line Biologic Therapy in Patients with Inflammatory Bowel Disease.”

UpToDate: “Overview of medical management of high-risk, adult patients with moderate to severe Crohn disease.”

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