Management of Crohn's Disease

Definition and Treatment Options

• Crohn's disease is defined as steroid refractory disease when active disease persists despite an adequate dose and duration of prednisolone (>20 mg/day for >2 weeks), while steroid dependence is defined as a relapse when the steroid dose is reduced below 20 mg/day, or within 6 weeks of stopping steroids, as per the European Crohn’s and Colitis Organisation 1
• The European Crohn’s and Colitis Organisation recommends first-line treatment with Anti-TNF therapy (infliximab, adalimumab) preferably combined with thiopurines for patients with moderate to severe Crohn's disease 2
• The European Crohn’s and Colitis Organisation recommends second-line treatment with Methotrexate (25 mg weekly parenteral) for patients who do not respond to first-line therapy 1, 3
• The following medications are recommended for specific indications and dosages:

Steroid-Sparing Strategies

• The European Society of Gastrointestinal Endoscopy recommends first-line steroid-sparing strategies with Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.25 mg/kg/day) for patients with steroid-dependent disease 1, 2
• The American Gastroenterological Association suggests alternative steroid-sparing strategies with Methotrexate (15-25 mg weekly, preferably parenteral) for patients who do not respond to first-line therapy 1
• Biologic therapy with or without an immunomodulator is recommended for moderate Crohn's disease, with options including TNF-α inhibitors (infliximab, adalimumab, certolizumab pegol), IL-12/23 inhibitors (ustekinumab), and anti-integrin agents (vedolizumab) 4, 3

Monitoring Response

• The American Gastroenterological Association recommends evaluating for steroid-free remission within 12-16 weeks, with regular assessment of disease activity using objective markers (endoscopy, CRP, fecal calprotectin) 2
• Ambulatory patients with Crohn's disease who are able to tolerate oral intake, have no signs of dehydration, no significant weight loss (<10%), no abdominal tenderness or mass, and no obstructive symptoms can be treated with first-line therapy, which includes budesonide 9 mg daily for 8 weeks or systemic corticosteroids, with response evaluation between 4-8 weeks for budesonide and 2-4 weeks for systemic corticosteroids 1, 2
• Patients with significant weight loss (>10%), abdominal pain, nausea/vomiting, anemia, fever, or failed response to treatment for mild disease require closer monitoring and potential escalation of therapy, with consideration of early biological therapy in high-risk patients 2, 5

Special Considerations

• Pregnancy and infection require special consideration, with consultation with specialists before initiating or continuing therapy and ruling out infectious causes (especially C. difficile) before attributing symptoms to disease flare 2
• Smoking cessation is strongly recommended as it worsens Crohn's disease, with a strong recommendation from the American College of Gastroenterology 6
• Prophylactic calcium and vitamin D should be used to prevent osteoporosis in patients on corticosteroids, as recommended by relevant medical guidelines 3
• Laboratory monitoring specific to each medication, as well as screening for tuberculosis and other infections before initiating biologic therapy, is recommended 4

Contraindications and Precautions

• Delaying biologic therapy in moderate disease, using 5-ASA compounds, prolonged corticosteroid use without a steroid-sparing strategy, failing to monitor for medication side effects, and not considering disease location when selecting therapy are all contraindicated or precautions to be taken 4, 7
• Using antibiotics for luminal disease outside of septic complications is not recommended, as stated by the American College of Gastroenterology 3
• Using corticosteroids for maintenance therapy due to significant side effects, including Cushing syndrome, acne, increased infection risk, hypertension, diabetes, osteoporosis, cataracts, and glaucoma 3, 2, 5
• Biological therapy may increase the risk of serious infections and potential malignancy, and screening for tuberculosis and other infections before initiating therapy is recommended 3