This paper is the first in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the diagnosis and management of Crohn's disease and concerns the methodology of the consensus process, and the classification, diagnosis and medical management of active and quiescent Crohn's disease. Surgical management as well as special situations including management of perianal Crohn's disease of this ECCO Consensus are covered in a subsequent second paper [Gionchetti et al JCC 2016].

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Aliment Pharmacol Ther 2011; 33: 987–995 Summary Background  Loss of response to anti‐TNF agents in Crohn’s disease is an emerging clinical problem. Aim  To review the causes, incidence and management approach of loss of response. Methods  A search of medical database (PubMed) and of meetings’ proceedings for definitions, causes and incidence of loss of response was carried out. Personal correspondence with principal investigators was conducted to retrieve missing data. Results  Various definitions of loss of response abound, hampering the ability to assess accurately the magnitude and management of this clinical problem. We propose to distinguish between a clinical worsening on anti‐TNF treatment and a true loss of response to anti‐TNFs. Accordingly, loss of response to anti‐TNFs at 12 months of therapy occurs in 23–46% of patients when judged by dose intensification, or 5–13% when gauged by drug discontinuation rates. The management of loss of response should allow for a period of watchful waiting as quite often the patients’ symptoms may resolve without alteration of therapy. If they do not, then identifying the correct mechanism responsible for clinical deterioration is prudent. Once symptoms are ascertained to arise from inflammatory IBD activity, drug level and antidrug antibody measurement can then help distinguish between non‐adherence to therapy, immunogenicity and non‐immune clearance of anti‐TNF, or an un‐chequered inflammation despite adequate anti‐TNF levels. The latter finding may be best addressed by a switch to another class of immunomodulators, whereas a low drug level should probably be managed by dose intensification or a switch to another anti‐TNF. Conclusion  Studies defining how best to translate drug‐level monitoring and other mechanistic considerations into clinical decisions are urgently needed.

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The advent of biological therapy has revolutionized inflammatory bowel disease (IBD) care. Nonetheless, not all patients require biological therapy. Selection of patients depends on clinical characteristics, previous response to other medical therapy, and comorbid conditions. Availability, reimbursement guidelines, and patient preferences guide the choice of first-line biological therapy for luminal Crohn's disease (CD). Infliximab (IFX) has the most extensive clinical trial data, but other biological agents (adalimumab (ADA), certolizumab pegol (CZP), and natalizumab (NAT)) appear to have similar benefits in CD. Steroid-refractory, steroid-dependent, or complex fistulizing CD are indications for starting biological therapy, after surgical drainage of any sepsis. For fistulizing CD, the efficacy of IFX for inducing fistula closure is best documented. Unique risks of NAT account for its labeling as a second-line biological agent in some countries. Patients who respond to induction therapy benefit from systematic re-treatment. The combination of IFX with azathioprine is better than monotherapy for induction of remission and mucosal healing up to 1 year in patients who are naïve to both agents. Whether this applies to other agents remains unknown. IFX is also effective for treatment-refractory, moderate, or severely active ulcerative colitis. Patients who have a diminished or loss of response to anti-tumor necrosis factor (TNF) therapy may respond to dose adjustment of the same agent or switching to another agent. Careful consideration should be given to the reasons for loss of response. There are insufficient data to make recommendations on when to stop anti-TNF therapy. Preliminary evidence suggests that a substantial proportion of patients in clinical remission for >1 year, without signs of active inflammation can remain in remission after stopping treatment.