Treatment of Crohn's Disease Exacerbation

First-Line Treatment Options

The European Crohn’s and Colitis Organisation recommends conventional glucocorticosteroids as first-line therapy for a first presentation or a single inflammatory exacerbation in a 12-month period 1
Conventional glucocorticosteroids are recommended as first-line therapy due to direct evidence of benefit compared to other treatments and no treatment 2
Health economic decision modeling has shown that starting with conventional glucocorticosteroid treatment is the most cost-effective approach for inflammatory exacerbation of Crohn's disease 2
The American Gastroenterological Association suggests considering budesonide for patients with distal ileal, ileocaecal, or right-sided colonic disease who decline, cannot tolerate, or have contraindications to conventional glucocorticosteroids 1
Enteral nutrition may be considered as an alternative to conventional glucocorticosteroids for children and young people with concerns about growth or side effects 1
The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends considering 5-aminosalicylates for patients who decline, cannot tolerate, or have contraindications to glucocorticosteroid treatment 1

The American College of Gastroenterology recommends adding azathioprine or mercaptopurine to conventional glucocorticosteroids or budesonide if there are two or more inflammatory exacerbations in a 12-month period, or if the glucocorticosteroid dose cannot be tapered 3
Thiopurine methyltransferase activity should be assessed before offering azathioprine or mercaptopurine 3
Methotrexate may be considered as an alternative to azathioprine or mercaptopurine if patients cannot tolerate these medications or have deficient thiopurine methyltransferase activity 3

The Crohn's and Colitis Foundation recommends TNF inhibitors, such as infliximab, adalimumab, and certolizumab pegol, for patients with moderate-to-severe Crohn's disease who have not responded to conventional therapy 4
Ustekinumab is recommended for induction of remission in patients with moderate-to-severe Crohn's disease with inadequate response to conventional therapy and/or to anti-TNF therapy 4
The National Institute for Health and Care Excellence suggests considering upadacitinib after failure of TNF-alpha inhibitors, providing an additional option with a novel mechanism of action 5

Patients taking azathioprine or mercaptopurine should be monitored for neutropenia, even if they have normal thiopurine methyltransferase activity 3
The British National Formulary recommends following guidance on monitoring immunosuppressives 3

The European Crohn’s and Colitis Organisation recommends treating any active proximal luminal disease with appropriate medications, such as budesonide, conventional corticosteroids, azathioprine, 6-mercaptopurine, methotrexate, or infliximab, for patients with perianal disease 6
Infliximab is effective for both reduction in draining fistulas and maintenance of fistula closure 6
The American Gastroenterological Association suggests considering azathioprine or mercaptopurine for maintenance of remission, particularly in patients with adverse prognostic factors 7