What are the treatment options for a Crohn's disease flare?

From the Guidelines

Treatment for a Crohn's disease flare typically involves a combination of medications to reduce inflammation and manage symptoms, with biologic agents being a key component for moderate to severe flares, as recommended by the most recent guidelines 1. For mild to moderate flares, oral corticosteroids like prednisone (40-60mg daily, tapered over 8-12 weeks) or budesonide (9mg daily for 8-12 weeks) are often first-line treatments, as suggested by the British Society of Gastroenterology consensus guidelines 1. Some key points to consider in the treatment of Crohn's disease flares include:

• The use of immunomodulators like azathioprine (2-3mg/kg/day), 6-mercaptopurine (1-1.5mg/kg/day), or methotrexate (25mg weekly) for maintenance therapy, as recommended by the British Society of Gastroenterology consensus guidelines 1.
• The effectiveness of biologic agents, including anti-TNF drugs (infliximab, adalimumab, certolizumab pegol), anti-integrin therapies (vedolizumab), and IL-12/23 inhibitors (ustekinumab), for moderate to severe flares, as supported by the ECCO guidelines on therapeutics in Crohn's disease 1 and the AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease 1.
• The importance of early introduction of biologic therapy, with or without an immunomodulator, rather than delaying their use until after failure of mesalamine and/or corticosteroids, as suggested by the AGA clinical practice guidelines 1. During flares, patients should maintain adequate hydration, consider a low-residue diet to reduce bowel irritation, rest as needed, and avoid NSAIDs which can worsen symptoms. Antibiotics like ciprofloxacin or metronidazole may be prescribed if infection is suspected, and these medications work by targeting different aspects of the inflammatory cascade that drives Crohn's disease, with the goal of inducing remission and preventing complications like strictures, fistulas, or abscesses.

From the FDA Drug Label

INDICATIONS AND USAGE HULIO 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.

DOSAGE AND ADMINISTRATION Crohn’s Disease (2. 3): • 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 • Pediatric Patients 6 Years of Age and Older: Pediatric Weight Recommended Dosage Days 1 and 15 Starting on Day 29 17 kg (37 lbs) to less than 40 kg (88 lbs) Day 1: 80 mg Day 15: 40 mg 20 mg every other week 40 kg (88 lbs) and greater Day 1: 160 mg (single dose or split over two consecutive days) Day 15: 80 mg 40 mg every other week

Treatment Options for Crohn's Disease Flare:

• Adalimumab (SQ): The recommended dosage for adults is 160 mg on Day 1,80 mg on Day 15, and 40 mg every other week starting on Day 29 2.
• Infliximab (IV): 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 3. Key Points:
• Adalimumab is administered subcutaneously.
• Infliximab is administered intravenously.
• Dosage may vary depending on patient weight and age.

From the Research

Treatment Options for Crohn's Disease Flare

The treatment options for a Crohn's disease flare include:

• Step-up therapy, which involves progressively increasing therapies with the increasing severity of the disease 4
• Top-down strategy, where biologicals together with thiopurines are used as first-line therapy, although this approach has been challenged by several arguments 4
• Medications such as:
  • Budesonide, which is preferred to prednisone for mild active Crohn's disease due to fewer side effects 4
  • Sulfasalazine, which may be used to treat active mild colonic disease 4
  • Mesalazine, which has been shown to be effective in the treatment of mild to moderate active Crohn's ileitis 5
  • Azathioprine, which has been confirmed to be effective in inducing remission in active Crohn's disease 4
  • Methotrexate, which is another effective medication for inducing remission in active Crohn's disease 4
• Antibiotics, which may be used if septic complications are suspected 4
• Topical treatment, which should be considered for distal disease 4

Induction and Maintenance Therapy

Induction therapy options include:

• Systemic corticosteroids, which have been established as an effective therapy for inducing remission in Crohn's disease 4
• Mesalamine derivatives, which have been shown to be effective in the treatment of Crohn's disease 6 Maintenance therapy options include:
• Azathioprine, which should be considered once remission has been achieved with systemic corticosteroids 4
• Mesalazine, which may reduce the risk of colon cancer, although this is still unproved in Crohn's disease 4

Specific Patient Groups

For patients with extensive colitis, long-term treatment with mesalazine may be an option 4 For patients with mild symptoms, no treatment may be an option 4 For patients with severe perineal disease, metronidazole may be effective 7