Published online Aug 28, 2018. doi: 10.3748/wjg.v24.i32.3567
Peer-review started: March 29, 2018
First decision: April 26, 2018
Revised: May 9, 2018
Accepted: June 25, 2018
Article in press: June 25, 2018
Published online: August 28, 2018
Core tip: Anti-tumor necrosis factor therapy should be considered as first-line therapy in patients with complicated Crohn’s disease and in acute-severe ulcerative colitis. Beyond these specific circumstances, the positioning of novel biologics and small molecules depends on the patient’s medical history, preference and disease phenotype. The efficacy and safety of using immunomodulatory therapy can be enhanced by adhering to therapeutic algorithms and using a ‘treat-to-target’ approach. The risks for adverse events due to poor disease control outweigh the risks associated with early aggressive therapy. In the setting of clinical and biochemical remission, following at least 6 mo of combined immunosuppressive therapy, consideration can be made to withdrawing thiopurine therapy in the correct patient with close follow-up.