What are the treatment options for abdominal pain associated with Crohn's disease?

From the Guidelines

For abdominal pain associated with Crohn's disease, the primary treatment approach involves managing inflammation and symptoms through medication and lifestyle changes, with a focus on a Mediterranean diet rich in fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins, as recommended by the most recent guidelines 1. Initial treatment typically includes:

• Anti-inflammatory drugs: Start with oral mesalamine (1.5-4.8 g/day) or sulfasalazine (3-6 g/day) for mild to moderate cases, as suggested by the ECCO guidelines 1.
• Corticosteroids: For moderate to severe flares, use prednisone (40-60 mg/day, tapering over 8-12 weeks) or budesonide (9 mg/day for 8-12 weeks), as recommended by the British Society of Gastroenterology consensus guidelines 1.
• Immunosuppressants: Consider azathioprine (2-3 mg/kg/day) or 6-mercaptopurine (1-1.5 mg/kg/day) for maintaining remission, as suggested by the ECCO guidelines 1.
• Biologics: For severe or refractory cases, use anti-TNF agents like infliximab (5 mg/kg IV at 0,2, and 6 weeks, then every 8 weeks) or adalimumab (160 mg SC initially, then 80 mg at week 2, followed by 40 mg every other week), as recommended by the ECCO guidelines 1. Additionally:
• Implement a Mediterranean diet, as recommended by the AGA clinical practice update 1.
• Ensure adequate hydration and consider nutritional supplements, as suggested by the AGA clinical practice update 1.
• Manage pain with acetaminophen; avoid NSAIDs as they can exacerbate symptoms. This approach targets the underlying inflammation causing abdominal pain in Crohn's disease, with a focus on dietary modifications to reduce mechanical irritation of the inflamed bowel, as recommended by the most recent guidelines 1.

From the FDA Drug Label

RENFLEXIS is a tumor necrosis factor (TNF) blocker indicated for: Crohn's Disease: • reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. • reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing disease. 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 treatment options for abdominal pain associated with Crohn's disease include:

• Infliximab (IV): reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy 2
• Adalimumab (SQ): treatment of moderately to severely active Crohn’s disease in adults and pediatric patients 6 years of age and older 3 Key points:
• Infliximab and adalimumab are both TNF blockers
• They are indicated for the treatment of moderately to severely active Crohn's disease
• They can help reduce signs and symptoms and induce and maintain clinical remission in adult and pediatric patients 2, 3

From the Research

Treatment Options for Abdominal Pain in Crohn's Disease

• The treatment of abdominal pain in Crohn's disease can be managed through various approaches, including pharmacological and non-pharmacological interventions 4.
• Medications such as mesalamine products, antibiotics, corticosteroids, azathioprine, 6-mercaptopurine, and anti-tumor necrosis factor agents may be used to manage mild to severe Crohn's disease 5.
• A "treat-to-target" approach, as outlined in the STRIDE-II guidelines, can help individualize treatment targets and improve symptom resolution, including abdominal pain, in patients with Crohn's disease 6.
• Some studies suggest that alternative therapies, such as a low FODMAP diet, mindfulness, stress management, and transcranial direct current stimulation, may be effective in reducing abdominal pain in patients with Crohn's disease, although the evidence is often of low certainty 4.
• The use of anti-TNF agents as first-line therapy may be considered for patients with complicated disease or bowel damage, and with poor prognostic factors and/or severe disease 7.

Non-Pharmacological Interventions

• Non-pharmacological interventions, such as relaxation training, yoga, and web-based education, have been studied as potential treatments for abdominal pain in Crohn's disease, although the evidence is often limited and of low certainty 4.
• A kefir diet, which contains Lactobacillus bacteria, has been studied as a potential treatment for abdominal pain in patients with Crohn's disease, although the evidence is limited and of low certainty 4.

Considerations for Treatment

• The treatment of abdominal pain in Crohn's disease should take into account the individual patient's disease stage, prognostic factors, and overall health status 7.
• A multidisciplinary approach, involving a family physician, gastroenterologist, and surgeon, may be necessary for the management of severe Crohn's disease 5.
• The role of central modulating factors, such as arousal, emotion, and cognitive factors, should be considered in the treatment of chronic pain in patients with Crohn's disease 8.