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

Management of Inpatient Crohn's Disease Flare

For patients hospitalized with a Crohn's disease flare, intravenous corticosteroids (methylprednisolone 40-60 mg/day) are the first-line treatment to induce symptomatic remission, with evaluation for response within 1 week to determine the need for treatment modification. 1, 2

Initial Assessment and Treatment

Severity-Based Treatment Approach

• Moderate to severe disease requiring hospitalization:

  • Intravenous methylprednisolone 40-60 mg/day 2, 1
  • Evaluate for response within 1 week 2
  • Response rates: 39% at day 3,76-78% at day 5, and 93% at day 10 2

• Mild to moderate disease with ileal/right colonic involvement:

  • Oral budesonide 9 mg/day if not requiring hospitalization 2, 1
  • Superior to placebo for inducing clinical response (RR: 1.46) and clinical remission (RR: 1.93) 2
  • Better safety profile than systemic corticosteroids 2

Monitoring Response

• Assess for symptomatic response to IV corticosteroids within 1 week 2, 1
• If inadequate response by day 5-7, consider early biological therapy 2

Treatment Escalation for Refractory Disease

Biological Therapy Options

1. Anti-TNF agents (strong recommendation, moderate evidence) 2:

   • Infliximab: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 3
   • Adalimumab: 160 mg SC initially, then 80 mg at week 2, followed by 40 mg every 2 weeks 4
   • Consider combination therapy with a thiopurine when starting infliximab 2, 1

2. Ustekinumab (strong recommendation, moderate evidence) 2, 1

3. Vedolizumab (conditional recommendation, low-moderate evidence) 2, 1

Important Considerations and Precautions

Corticosteroid Limitations

• Corticosteroids are effective for induction but not maintenance of remission 2, 5
• Approximately 50% of patients become steroid-dependent or have relapse within 1 year 6
• Significant adverse effects include:
  • Increased risk of infections (especially abdominal/pelvic abscesses) 2
  • Cushing syndrome, acne, ecchymoses, hypertension, diabetes 2
  • Osteoporosis, cataracts, glaucoma 2
  • Growth failure in children 2

Infection Screening

• Screen for tuberculosis before initiating biological therapy 3
• Evaluate for and treat any active infections before starting biologics 7
• Consider prophylactic calcium and vitamin D for patients on corticosteroids 2

Maintenance Therapy Planning

• Do not use corticosteroids for maintenance therapy 2, 1
• For patients responding to corticosteroids, plan early introduction of maintenance therapy with:
  • Thiopurines (azathioprine/6-mercaptopurine) 1, 8
  • Methotrexate 1, 8
  • Biological agents for high-risk patients 2, 1

Treatment Algorithm for Inpatient Crohn's Flare

1. Initial therapy: IV methylprednisolone 40-60 mg/day
2. Assess response within 1 week
3. If responding:
   • Continue IV steroids until clinical improvement
   • Transition to oral prednisone (typically 40-60 mg/day)
   • Plan taper over 8-12 weeks
   • Initiate maintenance therapy
4. If inadequate response:
   • Consider anti-TNF therapy (preferably infliximab due to IV administration in hospital setting)
   • Consider combination therapy with thiopurine if starting infliximab
   • Consider surgical consultation for complications (obstruction, abscess, perforation)

Remember that while corticosteroids are effective for acute management, they are not appropriate for long-term use, and maintenance therapy should be planned before discharge to prevent relapse and steroid dependence.