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MRI could be used by clinicians as an effective tool to monitor patients with Crohn's disease. In this Review, Gionata Fiorino, Cristiana Bonifacio, Luca Balzarini, Alberto Malesci and Silvio Danese discuss the development of objective MRI-based scores that enable evaluation of the extent of intestinal damage. They also speculate on the generation of a new 'damage-driven' treatment paradigm—in which imaging is used to monitor intestinal damage and medication use is targeted to prevent the accumulation of further damage

Evidence from a recent study strongly implicates innate immunity in the etiology of Crohn's disease, with particular focus on impaired secretion of cytokines and chemokines by intestinal macrophages in response to bacterial stimuli. These findings highlight the importance of acute inflammatory responses in the first stages of disease pathogenesis.

Evidence has accumulated to show that mucosal healing can alter the course of Crohn's disease. New results from the EXTEND trial clearly demonstrate that adalimumab is able to induce and maintain mucosal healing in Crohn's disease and has the potential for disease modification.

A recent study in a mouse model of colitis has demonstrated that interleukin (IL)-13, through inhibition of the mixed type 1 and type 17 T-helper cell inflammatory response, has a protective effect. The decoy receptor IL-13Rα2 inhibits this protective effect, suggesting blockade of IL-13Rα2 as a potential therapy for patients with IBD.

In 2013, several new IBD drugs, including golimumab and vedolizumab, have been approved or completed successful programmes, showing efficacy in both Crohn's disease and ulcerative colitis. In addition, classic IBD drugs have been formulated for colonic delivery, such as budesonide MMX^®, which was recently approved for mild-to-moderate ulcerative colitis.

Golimumab, a human anti-TNF antibody, is effective in patients with ulcerative colitis, according to new findings from an international phase III double-blind trial. The addition of this drug makes a ménage à trois of available drugs—comprising infliximab, adalimumab and golimumab—for the treatment of ulcerative colitis.

Biosimilar monoclonal antibodies are now being accepted in clinical practice by IBD specialists. However, switching patients already undergoing originator biologic treatment to biosimilars has been debated due to lack of controlled studies. The NOR-SWITCH study now provides novel clinical evidence in switching from originator to biosimilar in patients with IBD.

The landscape of treatment for IBD changed dramatically with the introduction of biologic agents, of which several are now in use for this condition. Here, the authors provide practical insights into the use of biologic agents in IBD, discussing issues such as comparative effectiveness, safety, immunogenicity, cost and patient preference.

Therapy for Crohn's disease has traditionally been based on a step-up approach, with treatment with the powerful TNF antagonists reserved as a last resort before surgery. In this Review, the authors discuss the use of anti-TNF agents as first-line therapy to achieve disease modification and the challenges in selecting appropriate patients for this approach.

Biologic agents have revolutionized the management of IBD and biosimilars (copy versions of the originator agents) are emerging as an alternative. This Review outlines the concept of biosimilars and their adoption in gastroenterology, their current use and future challenges.