Introduction: The advent of tumor necrosis factor (TNF) antagonists represented a radical change in the management of inflammatory bowel disease (IBD). Both in short- and long-term, anti-TNF therapy has been shown to reduce symptoms, heal mucosal ulcers, reduce hospitalizations and surgeries and spare corticosteroids.

Areas covered: A literature search to August 2013 was performed to identify the most relevant reports on the use of TNF antagonists in IBD. First, the authors focused on the mechanism of action of TNF antagonists. Second, they evaluated different indications, contraindications, the optimal time to start and the role of combining TNF antagonists with immunomodulators. Third, they explored the importance of mucosal healing, followed by the controversial topic on when TNF antagonists should be stopped. This is followed by the subjects of treatment failure, immunogenicity and therapeutic drug monitoring. Last, they analyzed safety issues including exposure to TNF antagonists during pregnancy.

Expert opinion: TNF antagonists have become indispensable in the management of IBD. Efforts to focus on treatment of inflammatory signs only and on optimization of treatment with therapeutic drug monitoring are underway. The advent of several new compounds and “biosimilars” will further challenge the position of TNF antagonists in the treatment algorithm of IBD.