Current dilemmas in the management of inflammatory bowel disease.

Considerable advances have been made in the treatment of inflammatory bowel disease (IBD) mainly in that of Crohn's disease, but many questions still remain. We need to develop treatments that modify the disease. The use of immunomodulation using cytokines and anti-cytokines is an important step to achieve this goal. The standard is now the chimeric monoclonal antibody against tumour necrosis factor (TNF) in Crohn's disease. These treatments, however, are associated with problems of immunogenicity and autoimmunity. Moreover a proportion of patients do not respond to treatment and we do not have measurements that predict response. The optimal use and the combined treatment with immunosuppression are under investigation. The safety of this treatment in the long-term is also not established. These costly drugs are not suitable for the management of mild to moderate Crohn's disease and ulcerative colitis (UC). If it turns out that the antigenic drive of the inappropriate immune reaction is in the lumen of the gut changing the gut flora by using probiotics may be the way to go.