Management of Crohn's Disease

Introduction to Treatment

Early introduction of biologic therapy with or without immunomodulators is recommended for moderate to severe Crohn's disease rather than delaying their use until after failure of mesalamine and/or corticosteroids 1

Disease severity should be determined based on a combination of symptoms, objective measures of inflammation, and factors that predict increased risk of complications 2
Treatment approach should be tailored to the severity of disease and location, taking into account patient preferences 3, 4
Smoking cessation is critical for maintaining remission and should be strongly advised for all patients with Crohn's disease 3, 4

For mild to moderate ileal/right colonic disease, oral budesonide 9 mg/day is suggested as first-line therapy 2, 5
For mild colonic disease, sulfasalazine 4-6 g/day may be used 2
For moderate disease that fails to respond to budesonide, conventional corticosteroids (prednisolone 40-60 mg/day) are recommended 2, 5
For moderate to severe disease, biologic agents are recommended for patients who fail conventional induction therapies 6, 7
Anti-TNF agents (infliximab, adalimumab) 6, vedolizumab 6, and ustekinumab 6 are options for biologic therapy

Corticosteroids (including budesonide) are not recommended for maintenance therapy 2, 3, 7
Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) are effective maintenance options for selected low-risk patients 3, 7
Methotrexate (15-25 mg weekly) is effective for patients whose active disease has responded to methotrexate 3, 6
Biologic agents should be continued in patients who responded to induction therapy with these agents 6, 7

Exclusive enteral nutrition is suggested for induction therapy in pediatric patients 8, 9
Anti-TNF agents are recommended for induction and maintenance therapy in severe pediatric disease or for patients who fail steroid and immunosuppressant therapies 8

Evaluate response to therapy within appropriate timeframes based on treatment, such as budesonide (4-8 weeks) 2, corticosteroids (2-4 weeks) 2, 5, anti-TNF agents (8-12 weeks) 6, vedolizumab (10-14 weeks) 6, and ustekinumab (6-10 weeks) 6
Patients in clinical remission on immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation 8