Crohn's disease (CD) is a chronic, relapsing disease, the continuous cycle of which deeply affects the long-term course which, eventually, leads to
fibrosis and development of transmural complications. It is well known that CD is an immune-mediated clinical condition and that
tumor necrosis factor-alpha (
TNF-alpha) plays a fundamental role in the pathogenesis of the disease. Current clinical guidelines recommend that patients with mild to moderate active CD should be treated initially with
corticosteroids. Although this approach is effective in inducing remission, some patients may become dependent on, or refractory to, these drugs in the long term, thus increasing the risk of developing
steroid-related adverse effects. A recent Cochrane systematic review established that
infliximab (IFX) is effective in inducing remission in patients with CD. Although only a few published studies have assessed IFX for the maintenance of remission in the long term, there is evidence that IFX is superior to placebo in sustaining clinical remission and
fistula healing; moreover,
corticosteroid-sparing effects have been demonstrated. IFX is associated with the formation of
antibodies to IFX which can lead to infusion reactions and shorter duration of response, but when comparing episodic vs scheduled maintenance treatment, the latter appears to sensibly reduce immunogenicity, thus offering improved efficacy and tolerance. The final point to consider is the best time to introduce IFX in the therapeutic algorithm of CD. Early use of IFX has been suggested to be more effective than late, and may potentially change the natural history of the disease. Effective induction and maintenance
therapy with IFX is the only means with which to maintain long-lasting clinical and mucosal remission which, in turn, may modify the long-term course of the disease. Furthermore, when treating
inflammatory bowel disease patients with IFX, an appropriate risk-benefit balance has to be taken into consideration, because the precise risk of serious adverse events associated with anti-TNF treatment in CD remains to be fully elucidated.