What is the treatment for an acute Crohn's disease flare?

Treatment of Acute Crohn's Disease Flare

For an acute Crohn's disease flare, corticosteroids are the first-line treatment, with oral prednisolone 40 mg daily recommended for moderate to severe disease, while intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for severe disease. 1

Treatment Algorithm Based on Disease Severity

Mild Disease

• High-dose mesalazine (4 g/day) may be sufficient initial therapy for mild ileocolonic Crohn's disease 1
• However, more recent guidelines note that 5-ASAs are not recommended for induction or maintenance treatment of Crohn's disease 1

Moderate to Severe Disease

1. Oral corticosteroids:

   • Prednisolone 40 mg daily 1
   • Should be reduced gradually over 8 weeks according to severity and patient response 1
   • Rapid reduction is associated with early relapse 1

2. For isolated ileo-cecal disease:

   • Budesonide 9 mg daily is appropriate (marginally less effective than prednisolone) 1

Severe Disease

1. Intravenous steroids:

   • Hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1
   • Concomitant intravenous metronidazole is often advisable to distinguish between active disease and septic complications 1

2. Supportive care:

   • Intravenous fluid and electrolyte replacement 1
   • Subcutaneous heparin for thromboembolism prophylaxis 1
   • Nutritional support if malnourished 1

Special Considerations

Alternative Therapies for Steroid-Resistant or Intolerant Patients

• Elemental or polymeric diets may be used to induce remission in selected patients with contraindications to corticosteroid therapy 1
• Infliximab is effective for patients with moderate to severe disease who have failed other therapies 1
  • Combination therapy of infliximab with a thiopurine is more effective than infliximab monotherapy 1

Maintenance Therapy Following Flare Resolution

After resolving the acute flare, early introduction of maintenance therapy should be considered:

• Thiopurines (azathioprine or mercaptopurine) are recommended for maintenance of remission 1
• Methotrexate (at least 15 mg weekly) is an alternative maintenance option 1
• Mesalazine is not recommended for maintenance therapy in Crohn's disease 1

Important Caveats and Pitfalls

1. Avoid delayed treatment: Prompt initiation of appropriate therapy is crucial to prevent disease progression and complications.

2. Rule out infections: Consider concomitant infections that may mimic or exacerbate Crohn's disease flares.

3. Steroid tapering: Too rapid reduction of steroids is associated with early relapse; follow a gradual 8-week taper schedule 1.

4. Mesalazine limitations: Despite historical use, current evidence does not support 5-ASAs for most Crohn's disease patients 1, 2.

5. Immunomodulator timing: Early introduction of maintenance therapy with thiopurines or methotrexate should be considered while tapering steroids to minimize risk of flare 1.

6. Monitor for complications: Regular assessment for signs of disease progression, steroid side effects, and treatment response is essential.