From the Guidelines
Biologics should be considered for ileal Crohn's disease when patients have high-risk features, fail conventional therapy, or have moderate to severe disease activity, as recommended by the most recent guidelines 1. When managing ileal Crohn's disease, it is essential to consider the severity of the disease, patient's age, and presence of high-risk features.
High-Risk Features
High-risk features that warrant earlier biologic initiation include:
- Complex disease at presentation, such as stricturing or penetrating disease
- Perianal fistulizing disease
- Age under 40 years at diagnosis
- Need for steroids to control the index flare These features are associated with a more aggressive disease course and increased risk of complications.
Conventional Therapy
First-line therapy typically includes corticosteroids (prednisone 40-60mg daily with taper over 8-12 weeks) and immunomodulators like azathioprine (2-2.5mg/kg/day) or 6-mercaptopurine (1-1.5mg/kg/day) 1. However, escalation to biologics is appropriate when patients show inadequate response to these medications after 2-3 months, become steroid-dependent, or experience frequent flares.
Biologic Therapy
Common biologics for ileal Crohn's include anti-TNF agents (infliximab, adalimumab, certolizumab pegol), anti-integrin therapy (vedolizumab), and IL-12/23 inhibitors (ustekinumab) 1. The choice between agents depends on disease phenotype, comorbidities, and patient preference regarding administration route and frequency.
Screening and Vaccination
Before starting biologics, patients should be screened for tuberculosis, hepatitis B, and other infections, and vaccination status should be updated 1.
Treatment Goals
The primary goal of treatment is to achieve and maintain mucosal healing, which is associated with reduced hospitalization, surgery rates, and improved quality of life 1. By considering these factors and following the most recent guidelines, clinicians can provide optimal care for patients with ileal Crohn's disease.
From the Research
Escalation to Biologics in Ileal Crohn's Disease
- The decision to escalate to biologics in ileal Crohn's disease should be based on the severity of the disease and the patient's response to initial treatment 2.
- Biologics such as infliximab, adalimumab, ustekinumab, and vedolizumab have been shown to be effective in treating moderate-to-severe Crohn's disease, including ileal disease 2, 3.
- However, the efficacy of biologics in treating proximal ileal lesions is relatively lower compared to the colon and terminal ileum 4.
Factors to Consider When Escalating to Biologics
- Disease severity and extent, including the presence of proximal ileal ulcerations 4.
- Patient's response to initial treatment, including the use of exclusive enteral nutrition (EEN) 5.
- Rapidity of action, safety, and comparative effectiveness of different biologics 2.
- Presence of extraintestinal manifestations (EIMs) and postoperative Crohn's disease 2.
Combination Therapy with Biologics and EEN
- Combination therapy with biologics and EEN has been shown to be an effective therapeutic strategy for small intestine diseases of active Crohn's disease 5.
- This approach may be considered for patients with moderate-to-severe ileal Crohn's disease who have not responded to biologics alone 5.