What is the best course of action for a 38-year-old female with a history of Crohn's (inflammatory bowel disease) disease on mesalamine (5-aminosalicylic acid) experiencing intermittent abdominal pain?

Management of Intermittent Abdominal Pain in a 38-Year-Old Female with Crohn's Disease on Mesalamine

For a 38-year-old female with Crohn's disease on mesalamine experiencing intermittent abdominal pain, mesalamine should be discontinued and therapy should be escalated to more effective treatments such as biologics, as mesalamine is not recommended for Crohn's disease management.

Assessment of Current Therapy

Mesalamine (5-ASA) is not recommended for Crohn's disease management based on current evidence:

• The American Gastroenterological Association (AGA) strongly recommends against the use of 5-ASA or sulfasalazine for induction or maintenance of remission in moderate to severe Crohn's disease 1.
• Multiple studies have shown that mesalamine is not effective for maintaining remission in Crohn's disease, with a relative risk of 1.02 (95% CI, 0.92-1.16) compared to placebo 1.
• While mesalamine has a robust safety profile, continuing an ineffective medication can lead to delays in appropriate therapy and worsening disease 1.

Diagnostic Approach for Abdominal Pain

When evaluating intermittent abdominal pain in a Crohn's disease patient:

1. Rule out complications:

   • Assess for obstruction, fistula formation, or abscess
   • Consider CT enterography or MR enterography to evaluate disease activity and complications
   • Check for perianal disease which may require different management

2. Laboratory evaluation:

   • Inflammatory markers (CRP, ESR, fecal calprotectin)
   • Complete blood count to assess for anemia or leukocytosis
   • Stool studies to rule out infectious causes

3. Endoscopic assessment:

   • Colonoscopy with ileoscopy to directly visualize disease activity
   • Consider upper endoscopy if upper GI symptoms are present

Treatment Algorithm

Step 1: Discontinue Mesalamine

• Mesalamine has been shown to be ineffective for Crohn's disease maintenance therapy 1
• Continuing ineffective therapy delays appropriate treatment and risks disease progression

Step 2: Determine Disease Severity

• Mild symptoms: Consider budesonide for short-term management
• Moderate to severe symptoms: Proceed to Step 3

Step 3: Initiate Effective Therapy

For moderate to severe Crohn's disease, the AGA recommends:

• First-line options:

  • Anti-TNF agents (infliximab, adalimumab)
  • Ustekinumab
  • Vedolizumab

• For perianal fistulizing disease:

  • Infliximab is strongly recommended (RR of failure to achieve remission=0.83) 1
  • Adalimumab, ustekinumab, or vedolizumab are conditionally recommended 1

Special Considerations

Monitoring

• Regular follow-up every 3-6 months during stable disease
• Assess for clinical response within 8-12 weeks of initiating new therapy
• Monitor for potential adverse effects of biologic therapy

Common Pitfalls to Avoid

1. Continuing ineffective therapy: Mesalamine has not shown benefit in Crohn's disease and may delay effective treatment 1.
2. Inadequate assessment: Failing to determine if symptoms represent active inflammation versus other causes (IBS, stricture, adhesions).
3. Overlooking complications: Missing fistulas, abscesses, or strictures that may require surgical intervention.
4. Steroid dependence: Repeated or prolonged courses of corticosteroids without escalation to steroid-sparing therapy.

Conclusion

The evidence clearly shows that mesalamine is not effective for Crohn's disease management. The patient's intermittent abdominal pain likely represents inadequately controlled disease activity. Discontinuing mesalamine and initiating appropriate biologic therapy based on disease severity and location is the recommended approach to improve outcomes related to morbidity, mortality, and quality of life.