Treatment of Crohn's Disease Flare

First-Line Treatment for Acute Flare

The European Crohn’s and Colitis Organisation recommends corticosteroids for inducing remission in moderate to severe Crohn's disease flares, with budesonide 9 mg/day preferred for disease limited to the ileum and/or ascending colon due to its better safety profile 1, 3, 4, 5
For more extensive or severe disease, systemic corticosteroids (prednisolone 40-60 mg/day) are recommended 2, 6

The American Gastroenterological Association recommends early introduction of biologics (TNF inhibitors) with or without immunomodulators after achieving remission with corticosteroids, with combination therapy with infliximab and a thiopurine being more effective than monotherapy for maintaining remission 1, 2, 9, 10
Thiopurines (azathioprine, mercaptopurine) or methotrexate should be considered for maintenance therapy after corticosteroid-induced remission, with methotrexate administered subcutaneously at a dose of at least 15 mg weekly with folic acid supplementation 2, 3, 10

For mild to moderate disease limited to the ileum and/or right colon, budesonide 9 mg/day is recommended, while systemic corticosteroids are recommended for more extensive disease or higher disease activity 2, 4, 5, 6
For moderate to severe disease, systemic corticosteroids are recommended for induction of remission, followed by early introduction of biologics (TNF inhibitors) with or without immunomodulators 1, 2, 6, 9

Mesalazine (5-ASA) is not recommended for induction or maintenance of remission in Crohn's disease, and antibiotics have not consistently demonstrated efficacy for luminal Crohn's disease 2, 3, 4
Evaluate response to corticosteroids within 2-4 weeks, and assess response to anti-TNF therapy between 8-12 weeks, with consideration of discontinuation and alternative treatment if no response by week 14 6