Inflammatory bowel disease (IBD) is a chronic, relapsing and remitting inflammation of the intestine, posing significant treatment challenges. Maintenance treatment with an immunomodulator (IM) and/or aminosalicylates is often required to reduce disease relapse in Crohn's disease (CD) and ulcerative colitis (UC). Despite adequate maintenance therapy, some patients experience disease flares that require escalation to biological therapy. [1,2] As there is currently no cure available for IBD, the treatment strategy for patients focuses on induction and maintenance of remission. As South Africa (SA) is a developing country and biological drug cost prohibitive, the (accelerated) step-up treatment strategy is used, with high-dose corticosteroids the favourite induction agent. This is followed by maintenance therapy with aminosalicylates or an IM to maintain remission. Examples of IM agents include azathioprine, 6-mercaptopurine and methotrexate. Thioguanine (Lanvis) is also used for severe IBD in an off-label setting in some centres. Patients who experience disease flares while receiving adequate doses of maintenance therapy and/or require a second course of high-dose corticosteroid therapy within a short treatment interval (usually 1 year), are escalated to biological therapy. Other indications for biological treatment include steroid-dependant and steroid-refractory disease. Since the launch of infliximab 20 years ago, the number of biological agents introduced to the market has grown exponentially, especially in the past decade. Currently available classes of biological agents for IBD in SA include: (i) tumour necrosis factor alpha (TNF alpha) antagonists, which include infliximab, adalimumab and golimumab; (ii) the integrin antagonist vedolizumab (Entyvio); and (iii) ustekinumab, a newly introduced interleukin (IL)-12 and IL-23 anta gonist (Stelara). [3-7] The last two agents are awaiting SA Health Products Regulatory Authority (SAHPRA) approval and currently only have limited availability on compassionate basis. Biological agents have revolutionised the treatment of IBD, especially over the past decade. A recent systematic review by Cote-Diagneault et al. [8] comprehensively summarised the success rate of IBD treatment with biologics. A detailed discussion of this topic is This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. De-escalation of biological therapy in inflammatory bowel disease: Benefits and risks E Fredericks, 1 FCP (SA), Cert Gastroenterology (SA), PhD; G Watermeyer, 2 FCP (SA), Cert Gastroenterology (SA), MPH (SA)