From the Guidelines
The best treatment approach for managing a Crohn's disease flare typically involves a combination of anti-inflammatory medications and supportive care tailored to the severity of symptoms, with a focus on early introduction of biologic therapy with or without an immunomodulator for moderate to severe cases, as recommended by the AGA clinical practice guidelines 1. For mild to moderate flares, oral corticosteroids such as prednisone (starting at 40mg daily and tapering over 8-12 weeks) or budesonide (9mg daily for 8-12 weeks) are often first-line treatments to quickly reduce inflammation, as suggested by the Canadian Association of Gastroenterology clinical practice guideline 1. These may be combined with 5-aminosalicylates like mesalamine (2.4-4.8g daily) for colonic disease, although the evidence for their effectiveness in moderate to severe Crohn's disease is limited 1. For moderate to severe flares, stronger immunosuppressants may be needed, including azathioprine (2-2.5mg/kg/day), 6-mercaptopurine (1-1.5mg/kg/day), or methotrexate (25mg weekly injection), with the goal of minimizing corticosteroid use and promoting early introduction of biologic therapy 1. In severe cases, biologic agents such as infliximab (5mg/kg IV at weeks 0,2, and 6, then every 8 weeks), adalimumab (160mg initially, 80mg at week 2, then 40mg every other week), or ustekinumab may be required, with the choice of biologic agent depending on patient-specific factors and disease characteristics 1. Supportive measures include maintaining hydration, following a low-residue diet during acute flares, pain management with acetaminophen (avoiding NSAIDs which can worsen symptoms), and possibly antibiotics if infection is suspected, as well as consideration of exclusive enteral nutrition (EEN) or a Crohn's disease exclusion diet for induction of clinical remission and endoscopic response in mild to moderate Crohn's disease of relatively short duration 1. These medications and supportive measures work by targeting different aspects of the inflammatory cascade that drives Crohn's disease, with corticosteroids providing broad anti-inflammatory effects while biologics target specific inflammatory pathways like TNF-alpha or interleukins, and dietary therapies aiming to reduce inflammation and promote healing. Treatment should be adjusted based on symptom response, and patients should be closely monitored for medication side effects and complications, with a focus on achieving and maintaining clinical remission and improving quality of life.
Some key considerations in managing Crohn's disease flares include:
- Determining disease severity based on a combination of symptoms, objective measures of inflammation, and factors that predict an increased risk of complications 1
- Evaluating symptomatic response to therapy and adjusting treatment accordingly 1
- Minimizing corticosteroid use and promoting early introduction of biologic therapy for moderate to severe cases 1
- Considering dietary therapies such as EEN or a Crohn's disease exclusion diet for induction of clinical remission and endoscopic response in mild to moderate Crohn's disease of relatively short duration 1
- Monitoring for medication side effects and complications, and adjusting treatment as needed to achieve and maintain clinical remission and improve quality of life.
Overall, the management of Crohn's disease flares requires a personalized and multifaceted approach, taking into account the severity of symptoms, disease characteristics, and patient-specific factors, with a focus on achieving and maintaining clinical remission and improving quality of life.
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 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 HUMIRA is indicated for the treatment of moderately to severely active Crohn’s disease in adults and pediatric patients 6 years of age and older. 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
The best treatment approach for managing a Crohn's disease flare is to use medications such as infliximab (IV) or adalimumab (SQ).
- Infliximab (IV) is administered 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 thereafter.
- Adalimumab (SQ) is administered at a dose of 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. It is essential to closely monitor patients for signs and symptoms of infection during and after treatment with these medications 2 3.
From the Research
Treatment Approaches for Managing Crohn's Disease Flare
- The management of Crohn's disease flare involves various treatment approaches, including the use of aminosalicylates, corticosteroids, and biologics 4, 5, 6, 7, 8.
- For ambulatory outpatients with low-risk, mild, ileal or ileocolonic Crohn's disease, induction of remission with budesonide is recommended 4.
- For colonic Crohn's disease, sulfasalazine is a reasonable choice, although other aminosalicylates have no role in the treatment of Crohn's disease 4, 5, 6.
- High-dose mesalamine (≥ 2.4g) may be considered for inducing remission in selected patients with mild luminal Crohn's disease who prefer to avoid steroids 7, 8.
Efficacy of Aminosalicylates
- Sulfasalazine has modest efficacy compared to placebo and is inferior to corticosteroids for the treatment of mild to moderately active Crohn's disease 5, 6.
- Olsalazine and low-dose mesalamine (1 to 2 g/day) are not superior to placebo 5, 6.
- High-dose mesalamine (3 to 4.5 g/day) is not more effective than placebo for inducing response or remission 5, 6.