From the Guidelines
For a 30-year-old male patient with Crohn's disease and a stent in the terminal ileum, presenting with acute colitis unresponsive to infliximab, I recommend escalating to corticosteroid therapy, specifically oral prednisone 40-60mg daily, as the next step in management. This approach is based on the strong recommendation from the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease, which suggests the use of oral prednisone 40-60 mg/day to induce complete remission in patients with moderate to severe Crohn's disease 1. Given the patient's failure to respond to infliximab, a biologic therapy, and the presence of acute colitis, corticosteroid therapy is a reasonable next step to induce remission.
The patient's condition, with a stent in the terminal ileum and acute colitis, suggests a more severe disease course, which warrants aggressive management. The British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults also support the use of corticosteroids in patients with severe disease, with a recommendation to continue IV steroids or switch to oral prednisolone 40mg daily in patients with severe symptoms 2.
Key considerations in this patient's management include:
- Monitoring for steroid-related side effects
- Obtaining baseline labs before starting any new medications
- Screening for tuberculosis and hepatitis before initiating biologic therapy, if considered in the future
- Evaluating the patient's response to corticosteroid therapy within 3-5 days to determine the need for further modification of therapy
In terms of long-term management, the patient may require a steroid-sparing immunomodulator, such as azathioprine or 6-mercaptopurine, to maintain remission. However, the immediate priority is to induce remission using corticosteroid therapy. The patient's failure to respond to infliximab suggests that alternative biologic therapies or small molecule inhibitors may be considered in the future, but this should be guided by the patient's response to corticosteroid therapy and further evaluation by a gastroenterologist.
From the Research
Treatment Options for Crohn's Disease
The patient's condition, with Crohn's disease and a stent in the terminal ileum, presenting with acute colitis unresponsive to infliximab, requires a tailored approach to treatment.
- The primary goal of treatment is to induce and maintain remission in a safe and efficacious fashion 3.
- The 'step-up' approach includes the use of immunomodulators and newer biologic agents, while the 'step-down' approach can be considered individually based on the severity of Crohn's disease 3.
- Conventional therapies for ulcerative colitis and Crohn's disease include aminosalicylates, corticosteroids, thiopurines, methotrexate, and anti-tumor necrosis factor agents 4.
Management of Acute Severe Colitis
For acute severe colitis, the first-line medical treatment is intravenous corticosteroid at a dose of 0.8mg/kg/day of prednisone equivalent 5.
- In case of failure, a second line of medical treatment can be attempted in the absence of complications, with options including infliximab and ciclosporin 5.
- Thromboembolic prevention with low molecular weight heparin is essential in any patient with severe acute colitis 5.
Treatment Algorithms for Crohn's Disease
Treatment algorithms for Crohn's disease can guide the physician's decision making, taking into account factors such as location and severity of inflammation, disease behavior, and previous therapies 6.
- New compounds introduced in CD therapy, such as ustekinumab and vedolizumab, may be considered as part of the treatment options 6.
- An interdisciplinary discussion involving gastroenterologists, surgeons, and other specialists may help to optimize the treatment plan, especially in cases of fistulizing disease or postoperative medical prophylaxis 6.