From the Guidelines
The treatment approach for Crohn's disease involves a multifaceted strategy tailored to the individual's disease severity, location, and complications, with a focus on inducing and maintaining remission, healing the intestinal mucosa, preventing complications, and improving quality of life. The initial treatment typically includes anti-inflammatory medications such as aminosalicylates (mesalamine 2-4g daily) for mild disease or corticosteroids (prednisone 40-60mg daily, tapered over 8-12 weeks) for moderate to severe flares. For long-term management, immunomodulators like azathioprine (2-3mg/kg/day), 6-mercaptopurine (1-1.5mg/kg/day), or methotrexate (15-25mg weekly) are used to maintain remission, as supported by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1. Biologic therapies have revolutionized treatment, including anti-TNF agents (infliximab 5mg/kg at weeks 0,2,6, then every 8 weeks; adalimumab 160mg initially, 80mg at week 2, then 40mg every 2 weeks), anti-integrin therapies (vedolizumab), and IL-12/23 inhibitors (ustekinumab), with the Canadian Association of Gastroenterology recommending anti-TNF therapy for patients with moderate to severe inflammatory Crohn’s disease who have failed to achieve clinical remission with corticosteroids 1. Antibiotics like metronidazole or ciprofloxacin may be used for perianal disease or bacterial overgrowth. Nutritional support is crucial, with some patients benefiting from exclusive enteral nutrition, as recommended by the AGA clinical practice update on diet and nutritional therapies in patients with inflammatory bowel disease 1. Surgery becomes necessary for complications such as strictures, fistulas, or abscesses that don't respond to medical therapy. The ECCO guidelines on therapeutics in Crohn's disease also support the use of biologic therapies, such as ustekinumab or vedolizumab, in patients who fail anti-TNF therapy, and highlight the importance of considering patient characteristics, costs, risks, and local regulations when making treatment decisions 1. Key considerations in treatment include:
- Inducing and maintaining remission
- Healing the intestinal mucosa
- Preventing complications
- Improving quality of life
- Controlling inflammation through various pathways in the immune system
- Tailoring treatment to the individual's disease severity, location, and complications.
From the FDA Drug Label
RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy RENFLEXIS is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing 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
The treatment approach for Crohn's disease includes:
- Induction therapy: 5 mg/kg given as an intravenous infusion at 0,2, and 6 weeks
- Maintenance therapy: 5 mg/kg given as an intravenous infusion every 8 weeks
- Dose adjustment: Consideration may be given to treatment with 10 mg/kg for adult patients who respond and then lose their response
- Concomitant medications: May include methotrexate, corticosteroids, antibiotics, and aminosalicylates 2 Key points to consider:
- Close monitoring: Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with RENFLEXIS
- Regular follow-up visits: Patients should have regular follow-up visits with a physician 2
- Contraindications: The combination of RENFLEXIS with other biological therapeutics used to treat the same conditions as RENFLEXIS is not recommended 2
From the Research
Treatment Approaches for Crohn's Disease
The treatment of Crohn's disease can be approached in two main ways: the step-up approach and the top-down approach.
- The step-up approach involves starting with mild treatments and gradually increasing the intensity of treatment as needed 3, 4, 5.
- The top-down approach involves starting with more aggressive treatments, such as biologic therapy, and then stepping down to less intense treatments as the disease comes under control 4, 6.
Medications Used in Treatment
Various medications can be used to treat Crohn's disease, including:
- Azathioprine (AZA) and 6-mercaptopurine (6-MP), which have been shown to be effective for maintaining remission in quiescent Crohn's disease 7.
- Biologic therapies, such as infliximab, which can be used in combination with immunomodulators to achieve rapid and sustained remission 4, 6.
- Corticosteroids, which can be used to induce remission but may have significant side effects 3, 5.
Factors Influencing Treatment Choice
The choice of treatment approach and medications depends on various factors, including:
- Disease severity and extent 4, 5.
- Patient age and comorbidities 4.
- Genetic and serologic testing results 4.
- Presence of complications, such as strictures or fistulas 4, 6.
Other Treatment Options
In addition to medications, other treatment options for Crohn's disease include:
- Surgery, which may be necessary to remove damaged portions of the intestine or to treat complications such as bowel obstruction or abscesses 4.
- Leukocytapheresis, which involves removing white blood cells from the blood to reduce inflammation 4.
- Stem cell therapy, which is still an experimental treatment for Crohn's disease 4.