From the Guidelines
The management of Crohn's disease exacerbation should prioritize the use of anti-TNF biologics, such as infliximab or adalimumab, as first-line therapy for induction and maintenance of remission in patients with moderate to severe luminal Crohn's disease, as recommended by the AGA clinical practice guidelines 1.
Key Considerations
- For mild to moderate flares, oral corticosteroids like prednisone (40-60mg daily with a 4-8 week taper) may be considered as first-line treatment, with budesonide (9mg daily for 8-12 weeks) preferred for ileal or right-sided colonic disease due to fewer systemic side effects 1.
- Anti-inflammatory medications such as 5-aminosalicylates (mesalamine 2.4-4.8g daily) can help in mild cases, particularly with colonic involvement, but their use is not recommended for induction or maintenance of remission in patients with Crohn's disease of any severity 1.
- In severe or steroid-refractory cases, biologic agents like ustekinumab may be required, and antibiotics such as ciprofloxacin (500mg twice daily) and metronidazole (500mg three times daily) are added when infection is suspected or for perianal disease.
Treatment Approach
- The goal is to induce remission quickly while preventing complications and transitioning to an effective maintenance therapy to prevent future flares.
- Hospitalization may be necessary for moderate to severe exacerbations, with intravenous corticosteroids (methylprednisolone 40-60mg daily), bowel rest, and possibly total parenteral nutrition.
- It's essential to monitor for complications like obstruction, abscess formation, or fistulae that may require surgical intervention.
Maintenance Therapy
- Immunomodulators such as azathioprine, mercaptopurine, or methotrexate are effective in the maintenance of remission of Crohn's disease, particularly in patients with moderate to severe disease 1.
- Biologic agents like infliximab, adalimumab, or ustekinumab may be required for maintenance of remission in patients with moderate to severe luminal Crohn's disease, as recommended by the AGA clinical practice guidelines 1.
From the FDA Drug Label
- 1 Crohn's Disease The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adults with moderately to severely active Crohn's disease or fistulizing Crohn's disease For adult patients who respond and then lose their response, consideration may be given to treatment with 10 mg/kg.
The management of Crohn's exacerbation involves the use of infliximab (IV) at a dose of 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks. If patients respond and then lose their response, consideration may be given to treatment with 10 mg/kg 2.
- Key points:
- Induction regimen: 5 mg/kg at 0,2, and 6 weeks
- Maintenance regimen: 5 mg/kg every 8 weeks
- Dose escalation: 10 mg/kg for patients who respond and then lose their response
- Important consideration: Patients who do not respond by Week 14 are unlikely to respond with continued dosing, and consideration should be given to discontinue infliximab (IV) 2.
From the Research
Management of Crohn's Exacerbation
The management of Crohn's exacerbation involves several treatment options, including:
- First-line therapy with steroids for rapid palliation of symptoms during initiation of anti-tumor necrosis factor α therapy 3
- Monoclonal antibodies to IL-12/23 or integrin α4β7, immunomodulators, combination therapies, or surgery 3
- Corticosteroids, which have been used for decades to treat active Crohn's disease and remain the mainstay in the management of moderate-to-severe relapses in Crohn's disease 4
- High-dose budesonide, which is an effective treatment for inducing remission in mild-to-moderate Crohn's disease 5, 6
- High-dose mesalamine, which is an option among patients preferring to avoid steroids 5, 6
Treatment Decisions
Treatment decisions are guided by disease severity and risk of poor outcomes 7. Patients with higher-risk disease are given biologics, with or without immunomodulators, to induce and maintain remission 7. For children, enteral nutrition is an option for induction therapy 7.
Prevention Measures
All patients with Crohn's disease should be counseled on smoking avoidance or cessation 7. Patients with Crohn's disease are at increased risk of cancer, osteoporosis, anemia, nutritional deficiencies, depression, infection, and thrombotic events, and maximizing prevention measures is essential in caring for these patients 7. Vaccinations to prevent infections, such as influenza, pneumonia, and herpes zoster, are important components of health maintenance for patients with Crohn's disease, although live vaccines are contraindicated for patients receiving immune suppression therapy 3.