TREATMENT OF THE STEROID-RESISTANT PATIENT

Although refractory inflammatory bowel disease (IBD) can be handled surgically or by nutritional supplementation or replacement in a subset of patients, immunosuppressive agents have gained widespread acceptance over the past several years. This is based upon a large number of uncontrolled and several controlled clinical trials demonstrating efficacy as well as the realization that side effects caused by immunosuppressive agents are dwarfed by those caused by long term, high-dose corticosteroids. Whereas 6-mercaptopurine and azathioprine remain the drugs of choice based upon extensive clinical experience, both methotrexate and cyclosporin appear promising for otherwise refractory disease. The recent discovery of a P-glycoprotein efflux pump that promotes resistance to a large number of structurally related antineoplastic drugs, and recent attempts to inhibit induction of this pump, may have future implications for the use of immunosuppressive agents in IBD.