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

From the Guidelines

Treatment for a Crohn's disease flare should prioritize early introduction of biologics with or without an immunomodulator, as suggested by the AGA clinical practice guidelines 1. For mild to moderate flares, oral corticosteroids like prednisone (typically 40mg daily, tapered over 8-12 weeks) or budesonide (9mg daily for 8-12 weeks) are often first-line treatments. Some key points to consider in treatment include:

• Anti-inflammatory medications such as mesalamine (2-4g daily) may help some patients, particularly those with colonic disease.
• For moderate to severe flares, biologics are frequently used, including anti-TNF agents like 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 certolizumab pegol.
• Other biologic options include ustekinumab, vedolizumab, or risankizumab.
• Immunomodulators like azathioprine (2-2.5mg/kg/day), 6-mercaptopurine (1-1.5mg/kg/day), or methotrexate (25mg weekly) may be added for maintenance, as supported by guidelines from the British Society of Gastroenterology 1.
• During flares, patients should avoid trigger foods, stay hydrated, and consider a low-residue diet temporarily.
• Antibiotics like ciprofloxacin or metronidazole may be prescribed if infection is suspected, and for severe flares unresponsive to medication, hospitalization for IV steroids, bowel rest, or surgery may be necessary, as outlined in the ECCO guidelines on therapeutics in Crohn's disease 1. The use of biologics and immunomodulators is supported by high-quality evidence from recent studies, including those published in 2021 1, which emphasize the importance of early and aggressive treatment to induce and maintain remission in Crohn's disease.

From the FDA Drug Label

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 (HULIO) is indicated for the treatment of moderately to severely active Crohn's disease in adults and pediatric patients 6 years of age and older.
• 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.
• For pediatric patients 6 years of age and older, the recommended dosage is based on weight, with 80 mg on Day 1 and 40 mg on Day 15 for patients weighing 17 kg to less than 40 kg, and 160 mg on Day 1 and 80 mg on Day 15 for patients weighing 40 kg or more. 2

REMICADE 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.

Pediatric Crohn's Disease: reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active disease who have had an inadequate response to conventional therapy.

Alternative Treatment Option:

• Infliximab (REMICADE) is also indicated for the treatment of Crohn's disease, including reducing signs and symptoms and inducing and maintaining clinical remission in adult and pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. 3

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