From the Guidelines
For Crohn's disease with small bowel ulcerations but no diarrhea, regular bowel movements, and normal calprotectin, treatment is still recommended despite minimal symptoms, with the preferred approach being to start with a biologic therapy such as adalimumab or infliximab, as these medications target the underlying inflammation and promote mucosal healing, as suggested by the most recent guidelines 1. The goal of treatment in this scenario is to prevent disease progression and complications, such as strictures, fistulas, or abscesses, which can occur over time if the ulcerations are left untreated.
- The treatment approach should be individualized, taking into account the patient's overall health, medical history, and the extent of the disease.
- Regular monitoring with calprotectin tests every 3-6 months and follow-up imaging or endoscopy after 6-12 months of treatment is important to assess mucosal healing, as recommended by the AGA clinical practice guideline on the role of biomarkers for the management of Crohn's disease 1.
- An immunomodulator like azathioprine or 6-mercaptopurine might be added for combination therapy in certain cases, as suggested by the ECCO guidelines on therapeutics in Crohn's disease: medical treatment 1.
- The British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults also recommend a strong approach to treating Crohn's disease, even in the absence of symptoms, to prevent long-term complications 1. The "treat-to-target" approach, which aims for both clinical and endoscopic remission, is the most effective way to manage Crohn's disease and prevent disease progression, as it allows for early intervention and adjustment of treatment as needed, based on the latest evidence from the European evidence-based consensus for endoscopy in inflammatory bowel disease 1.
From the FDA Drug Label
To treat moderate to severe Crohn’s disease (CD) in adults and children 6 years of age and older. The FDA drug label does not answer the question.
From the Research
Treatment of Crohn's Disease
- The patient has Crohn's disease with no diarrhea, regular bowel movements, normal calprotectin, but many small ulcerations in the small bowel on capsule endoscopy.
- The treatment options for Crohn's disease are varied and depend on the severity of the disease and the presence of complications.
Azathioprine for Maintenance of Remission
- Azathioprine has been shown to be effective in maintaining remission in patients with Crohn's disease 2, 3.
- A meta-analysis of 11 studies found that azathioprine was significantly superior to placebo for maintenance of remission over a 6 to 18 month period 2.
- Another study found that azathioprine was superior to budesonide in achieving and maintaining mucosal healing and histologic remission in steroid-dependent Crohn's disease 4.
Role of Small Bowel Endoscopy
- Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection 5.
- Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required.
Treatment Options
- The treatment options for the patient include azathioprine, which has been shown to be effective in maintaining remission in patients with Crohn's disease.
- The patient's normal calprotectin levels and regular bowel movements suggest that the disease is not actively inflamed, but the presence of small ulcerations in the small bowel on capsule endoscopy indicates that the disease is still active.
- Azathioprine may be a suitable treatment option for this patient, but the decision to start treatment should be made on a case-by-case basis, taking into account the patient's individual circumstances and medical history 2, 6, 3.