It is an exciting time to be involved in IBD research and hopefully it is becoming less frustrating for patients. IBD are complex diseases involving genetics and environment. For researchers this is like a series of jigsaws where we know what the final pictures look like, but for which we have many, but not all, the pieces. However, knowledge from genetic studies in patients and new developments in basic research are coming together to help solve these puzzles.

Benefits to patients will emerge progressively as these puzzles are solved. The advent of infliximab is a good example of the transition from understanding the disease process to treatment. Basic research told us that the cytokine TNF-a was an important element of the unnecessary immune responses in both Crohn's disease and ulcerative colitis. Consequently infliximab, which is an antibody that deactivates TNF-a, was tested in clinical trials and shown to be an effective new treatment for many patients. This is an example of what we call rational drug design, that is designing a drug to do a specific job in a patient with a disease.

Like infliximab, most of the current IBD drugs in different ways reduce the intensity of the immune response in IBD (so called anti-inflammatory drugs). We now understand quite a lot about the nature of this immune response. However, a major challenge facing the field is to uncover what initiates this type of response in IBD patients. If we can understand what initiates the disease then there is a prospect for rational design of drugs that stop the immune response being initiated. Whilst the current anti-inflammatory drugs might still be needed to treat patients with severe inflammation, drugs targeting the initiating events could prevent disease or help patients remain in remission. The hope with these drugs is not only that will they be effective but they will have fewer side effects than the anti-inflammatory drugs.

Not all drugs will ensue from rational drug design and new drugs may also emerge from natural compounds. As an example, we are conducting pre-clinical testing of a new drug isolated from pineapple stems. A crude preparation from pineapples stems known as bromelain has been known for some time to have anti-inflammatory properties. However, like many of these natural compounds, bromelain is a complex mix of many biologically active compounds. The danger with such a cocktail is that some components may be good for you whilst others could have adverse effects. The Australian biotechnology company, Incitive Ltd, has isolated some of the beneficial molecules from pineapple stems. At the Mater Medical Research Institute we have been testing this new drug in preclinical animal models of IBD with promising results. Together with Incitive we will be trying to identify how this drug works to lessen the symptoms of IBD. If we can understand how the drug works it opens up the opportunity to modify the drug to make it more effective or even to rationally design new drugs targeting the same pathway.

Ultimately, any new drug needs to be subjected to the rigours of clinical trial before it should be recommended for use in patients. Clinical trials are designed to work out appropriate doses of drugs, assess their effectiveness in different types of patients, and importantly to assess any unwanted side effects. Patients should be wary of using any drugs not tested in properly designed trials. Conversely, patients should be open to trying untested drugs in properly conceived and executed trials, because this will benefit not only them but also fellow-patients with IBD.

Incidence of IBD increased in the Western world in the early 20th Century and is now increasing in Asia. Environmental exposures are clearly important in IBD as identical twins of IBD sufferers don't necessarily get the disease. If we can understand the environmental triggers for IBD we may be able to modify exposure to prevent disease. Modifications to the intestinal environment may even be able to be used to reverse the disease process in patients with IBD.

Despite the major effect of environment, rapidly evolving knowledge about the structure and function of the human genome is contributing to solving the IBD jigsaws. It will not be long before we are subclassifying patients with Crohn's disease and ulcerative colitis into subgroups based on genetics. These subgroups will effectively represent different diseases which require different strategies for treatment. Not only will new drugs contribute here, but correct disease classification will allow more appropriate prescription of the available drugs.

Scientific advances are incremental and the shifts in treatment that follow will also be incremental. However, the long term future can only be brighter for those of you unlucky enough to suffer from these diseases.