What is the treatment for an active Crohn's (Crohn's disease) flare?

From the Guidelines

Treatment for an active Crohn's disease flare typically involves a combination of medications to reduce inflammation and manage symptoms, with biologic agents like infliximab or adalimumab recommended as first-line therapy for moderate to severe luminal Crohn's disease with risk factors of poor prognosis, as suggested by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1.

Key Considerations

• The goal of treatment is to reduce inflammation, manage symptoms, and improve quality of life, while minimizing the risk of complications and mortality.
• The choice of treatment depends on the severity of the disease, the location of the disease, and the presence of complications.
• Biologic agents like infliximab (5mg/kg IV at weeks 0,2, and 6, then every 8 weeks) or adalimumab (160mg initially, 80mg at week 2, then 40mg every other week) are effective in inducing and maintaining clinical remission in patients with moderate to severe Crohn's disease, as recommended by the AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease 1.

Treatment Options

• Corticosteroids such as prednisone (40-60mg daily, tapered over 8-12 weeks) or budesonide (9mg daily for 8-12 weeks) can quickly reduce inflammation, but should be avoided as maintenance therapy due to toxicity and lack of efficacy, as recommended by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
• Immunomodulators such as azathioprine (2-3mg/kg/day), 6-mercaptopurine (1-1.5mg/kg/day), or methotrexate (25mg weekly) may be used to maintain remission, but are not effective in inducing remission, as suggested by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1.
• Anti-TNF biologics like infliximab or adalimumab are recommended as first-line therapy for moderate to severe luminal Crohn's disease with risk factors of poor prognosis, as suggested by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1.

Lifestyle Modifications

• Patients should maintain adequate hydration, consider a low-residue diet to reduce bowel irritation, and avoid NSAIDs which can worsen symptoms.
• Antibiotics like ciprofloxacin or metronidazole may be prescribed if infection is suspected.

Monitoring and Follow-up

• Patients should be evaluated for symptomatic response to treatment between 8 and 12 weeks to determine the need to modify therapy, as recommended by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1.
• Regular follow-up appointments with a healthcare provider are necessary to monitor disease activity, adjust treatment as needed, and prevent 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 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: 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 treatment for an active Crohn's flare is induction and maintenance therapy with medications such as:

• Infliximab (IV): 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 2
• Adalimumab (SQ): 160 mg on Day 1,80 mg on Day 15, and 40 mg every other week starting on Day 29 3 Key points:
• These medications are indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease.
• The dosage and administration may vary depending on the patient's response and medical history.

From the Research

Treatment Options for Active Crohn's Flare

• The treatment of active Crohn's disease can be considered in relation to the treatment of acute disease and the maintenance of remission 4.
• Medications used to achieve these two goals may or may not be the same.
• Some patients with mildly active disease may respond to high-dose (4 g/day) mesalazine (mesalamine), and 5-aminosalicylic acid may also be helpful in weaning a patient off steroids after treatment for a flare-up 4.

Induction of Remission

• Steroids form the first-line therapy for acute episodes of inflammation but do not maintain remission 4.
• Azathioprine and mercaptopurine are the first-line drugs for the maintenance of remission in moderate to severe Crohn's disease 4.
• Methotrexate is effective in inducing and maintaining remission, and is useful for patients who fail azathioprine treatment 4.
• Infliximab can induce and maintain remission in patients resistant to other therapies, with two-thirds of patients initially responding to treatment 4.

Maintenance of Remission

• Azathioprine or 6-mercaptopurine therapy may allow patients to reduce steroid consumption 5.
• The combination of azathioprine and infliximab was significantly superior to infliximab alone for induction of steroid-free clinical remission 5.
• Adalimumab and infliximab + azathioprine are the most effective therapies for induction and maintenance of remission of Crohn's disease 6.

Mild Crohn's Disease

• For ambulatory outpatients with low-risk, mild, ileal or ileocolonic CD, induction of remission with budesonide is recommended 7.
• For colonic CD, sulfasalazine is a reasonable choice, although other aminosalicylates have no role in the treatment of CD 7.
• Select patients with mild-to-moderate CD may benefit from maintenance therapy with azathioprines or gut-specific biologics, such as vedolizumab 7.