From the Guidelines
Management of Crohn's disease exacerbation requires prompt intervention with a step-up approach based on disease severity, with anti-TNF biologics such as infliximab or adalimumab being the preferred treatment for moderate to severe luminal Crohn’s disease with risk factors of poor prognosis, as recommended by the AGA clinical practice guidelines 1.
Disease Severity Assessment
The management of Crohn's disease exacerbation should start with the determination of disease severity, which should be based on a combination of symptoms, objective measures of inflammation, and factors that predict an increased risk of complications, as suggested by the Canadian Association of Gastroenterology clinical practice guideline 1.
Treatment Approach
For mild to moderate flares, oral corticosteroids such as prednisone 40mg daily with a 4-8 week taper may be considered, but the use of systemic corticosteroids should be balanced against the potential risks, including Cushing syndrome, acne, infection, and osteoporosis, as highlighted in the ECCO guidelines on therapeutics in Crohn's disease 1.
Biologics
In moderate to severe exacerbations, biologics such as anti-TNF agents (infliximab or adalimumab), vedolizumab, or ustekinumab should be considered, with the choice of biologic depending on the patient's previous response to therapy and the presence of any contraindications, as recommended by the AGA clinical practice guidelines 1.
Antibiotics and Hospitalization
Antibiotics like ciprofloxacin and metronidazole may be indicated if infection is suspected, and hospitalization may be necessary for severe exacerbations with IV steroids, bowel rest, and IV fluids, as outlined in the example answer.
Pain Management and Nutritional Support
Pain management should be addressed with acetaminophen or, if necessary, low-dose opioids, avoiding NSAIDs which can worsen disease, and nutritional support is crucial, potentially including enteral nutrition, to prevent malnutrition and support the healing of the intestinal mucosa.
Monitoring for Complications
Throughout treatment, monitor for complications like obstruction, abscess, or fistula formation which may require surgical intervention, and adjust maintenance therapy to prevent future flares, as repeated exacerbations can lead to intestinal damage and complications.
- Key considerations in the management of Crohn's disease exacerbation include:
- Disease severity assessment
- Treatment approach, including the use of corticosteroids, biologics, and antibiotics
- Pain management and nutritional support
- Monitoring for complications and adjusting maintenance therapy to prevent future flares.
From the FDA Drug Label
HUMIRA is a tumor necrosis factor (TNF) blocker indicated for: Crohn’s Disease (CD) (1.5): treatment of moderately to severely active Crohn’s disease in adults and pediatric patients 6 years of age and older.
The management of Crohn's Disease exacerbation with adalimumab (HUMIRA) involves the following dosage:
- Adults: 160 mg on Day 1 (given in one day or split over two consecutive days); 80 mg on Day 15; and 40 mg every other week starting on Day 29
- Pediatric Patients 6 Years of Age and Older:
- 17 kg (37 lbs) to less than 40 kg (88 lbs): Day 1: 80 mg, Day 15: 40 mg, and 20 mg every other week starting on Day 29
- 40 kg (88 lbs) and greater: Day 1: 160 mg (single dose or split over two consecutive days), Day 15: 80 mg, and 40 mg every other week starting on Day 29 2
From the Research
Management of Crohn's Disease Exacerbation
- The management of Crohn's disease exacerbation involves the use of various therapies, including infliximab, azathioprine, and 6-mercaptopurine, to induce and maintain remission 3, 4, 5, 6, 7.
- Infliximab is indicated for the treatment of signs and symptoms, and induction and maintenance of remission in patients with moderate to severely active inflammatory Crohn's disease 3.
- Azathioprine and 6-mercaptopurine are effective in chronic active disease and corticosteroid-dependent Crohn's disease, and may allow patients to reduce steroid consumption 6.
- The combination of azathioprine and infliximab was superior to infliximab alone for induction of steroid-free remission 6.
- Azathioprine is more effective than placebo for maintenance of remission in Crohn's disease, but its use is limited by adverse effects 7.
Treatment Options
- Infliximab: 5 mg/kg initially, with maintenance dosing every 8 weeks 3.
- Azathioprine: 1.0 to 2.5 mg/kg/day for maintenance of remission 7.
- 6-mercaptopurine: 1.0 mg/day for maintenance of remission 7.
- Combination therapy: azathioprine and infliximab for induction of steroid-free remission 6.