A stepwise approach (now generally referred to as the step-up approach), such as outlined in the following sections, may be taken in mild to very moderate inflammatory bowel disease (IBD).

The first step in medication therapy for IBD is usually aminosalicylates. There are several different aminosalicylates, but none have been consistently demonstrated to be superior to the others for all patients. These agents appear to have greater efficacy for the treatment of ulcerative colitis than for Crohn disease, for which efficacy data are limited. For Crohn disease, metronidazole or ciprofloxacin is occasionally used, particularly for perianal disease or an inflammatory mass.

If the patient's condition fails to respond to an adequate dose of aminosalicylates, the second step is often corticosteroids, which tend to provide rapid relief of symptoms and a significant decrease in inflammation.^[82] The most common range for moderate flares of IBD is oral prednisone at 10-40 mg/day; for more severe flares, the higher end of the range is used (occasionally doses up to 60 mg/day are required). Once a clinical response is seen, the dose is tapered. Most patients who use oral corticosteroids can tolerate a relatively rapid taper after a response is achieved; occasionally, a very prolonged steroid taper is necessary to prevent relapse in patients who have had prolonged exposure to steroids in the past. Inability to taper down the steroids without recurrence of symptoms should trigger discussion regarding the use of alternative drugs (immunomodulators or anti-TNF therapy).

The immune-modifying agents are step III drugs and are used if corticosteroids fail or are required for prolonged periods. Anti-TNF monoclonal antibody therapies are also step III drugs that are effective in both Crohn disease and ulcerative colitis; some studies have demonstrated that they have a greater efficacy than azathioprine.

Drugs from different therapeutic classes may be used additively. In some patients with high-risk disease, a step-down approach with early introduction of stronger agents such as the anti-TNF agents has been advocated to prevent complications and improve patient outcomes. There are many situations, especially in patients with more severe disease, where the step-down approach is clearly in the patient’s best interest.

In general, one major goal is to wean the patient off steroids as soon as possible to prevent long-term adverse effects from these agents. Ardizzone et al suggest that a lack of mucosal healing after corticosteroid therapy is the only factor associated with negative outcomes at 5 years

Source: http://emedicine.medscape.com/article/179037-treatment#d10