Treatment Options for Crohn's Disease

Initial Treatment Approach

For mild to moderate Crohn's disease, systemic corticosteroids remain an effective initial therapy, regardless of disease location 2
For less severe symptoms in ileocecal disease, ileal-release budesonide may be tried first, but prednisolone may be required if ineffective 2
In teenagers where growth has not completed, or patients with diabetes or steroid intolerance, alternatives like exclusive enteral nutrition (EEN) should be considered 2
5-ASA compounds are not recommended for induction or maintenance of remission in Crohn's disease due to lack of efficacy 3, 4

TNF inhibitors (infliximab, adalimumab, certolizumab pegol) are recommended for induction of remission in patients with moderate-to-severe Crohn's disease who haven't responded to conventional therapy 5, 6
Combination therapy with a thiopurine when starting infliximab is recommended for patients with moderate-to-severe Crohn's disease with inadequate response to conventional therapy 6
Ustekinumab is recommended for induction of remission in patients with moderate-to-severe Crohn's disease with inadequate response to conventional therapy and/or anti-TNF therapy 5

Systemic or locally acting corticosteroids should be avoided as maintenance therapy due to toxicity and lack of efficacy 2
Azathioprine or mercaptopurine can be used as monotherapy for maintenance of remission 2
Continuing azathioprine is superior to withdrawal for avoiding clinical relapse in patients already in remission on this therapy 1
Immunomodulators (azathioprine, mercaptopurine, methotrexate) are effective for maintenance of remission and have corticosteroid-sparing effects 2

Early introduction of biologics may be considered in patients with aggressive disease course or "high-risk" poor prognostic factors, including complex disease at presentation, perianal fistulising disease, age under 40 years at diagnosis, and need for steroids to control the index flare 2, 4
The REACT trial showed early use of monoclonal antibodies combined with immunosuppressants in high-risk patients was associated with significantly lower rates of complications, hospitalizations, and surgeries compared to conventional stepwise management 8

Combination therapy with anti-TNF agents and immunomodulators may be associated with higher risk for lymphoma and serious infections compared to anti-TNF monotherapy 8
Thiopurine methyltransferase activity should be assessed before starting azathioprine or mercaptopurine to reduce risk of toxicity 9

Early effective treatment in moderate/severe Crohn's disease can lead to sustained, corticosteroid-free remission, with lower risk for hospitalizations and surgery 1