What are the latest guidelines for managing Crohn's disease?

Latest Guidelines on Crohn's Disease Management

The current guidelines recommend using biologics (anti-TNF agents, ustekinumab, or vedolizumab) as the cornerstone of therapy for moderate-to-severe Crohn's disease, while budesonide is recommended as first-line therapy for mild-to-moderate disease limited to the ileum and/or right colon. 1

Disease Classification and Initial Assessment

Disease severity in Crohn's disease is typically categorized as:

• Mild: Ambulatory patients with low-risk features, able to eat and drink normally without signs of dehydration, toxicity, abdominal tenderness, mass, or obstruction
• Moderate-to-severe: Patients who have failed treatment for mild disease or those with fever, weight loss, abdominal pain, nausea/vomiting, or anemia
• Severe/fulminant: Patients with persistent symptoms despite conventional therapy or those with high fever, persistent vomiting, evidence of intestinal obstruction, or cachexia

Treatment Recommendations by Disease Severity

Mild Disease

• Ileal or ileocolonic disease:

  • First-line: Oral budesonide 9 mg/day 1
  • Evaluate response between 4-8 weeks 1
  • Budesonide is not recommended for maintenance therapy 1

• Colonic disease:

  • First-line: Sulfasalazine 4-6 g/day may be used for mild colonic disease 1
  • Evaluate response between 2-4 months 1
  • Other 5-ASA compounds are not recommended for Crohn's disease of any severity 1

Moderate-to-Severe Disease

• First-line options:

  • If failed budesonide: Prednisone 40-60 mg/day 1
  • Evaluate response to prednisone between 2-4 weeks 1
  • For maintenance after steroid-induced remission: Consider thiopurines or methotrexate 1
  • Early introduction of biologics is suggested rather than delaying until after failure of mesalamine/corticosteroids 1

• Biologic therapy options:

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

Severe/Hospitalized Disease

• Intravenous corticosteroids (e.g., methylprednisolone 40-60 mg/day) 1
• Evaluate response within 1 week 1
• Consider early surgical consultation if no improvement

Maintenance Therapy

• Not recommended for maintenance:

  • Corticosteroids (strong recommendation) 1
  • 5-ASA compounds (strong recommendation) 1
  • Antibiotics 1

• Recommended for maintenance:

  • Thiopurines for steroid-dependent patients (strong recommendation) 1
  • Methotrexate for patients who achieved remission with methotrexate 1
  • Biologic agents (anti-TNF, ustekinumab, vedolizumab) 1, 2, 3

Special Considerations

Combination Therapy

• Combination of anti-TNF with immunomodulator may be more effective than monotherapy but carries increased risk of adverse events 1
• After achieving long-term remission with combination therapy, monotherapy with infliximab or adalimumab may be considered 1

Treatment After Anti-TNF Failure

• For primary non-responders to anti-TNF: Ustekinumab (recommended) or vedolizumab (suggested) 1
• For secondary non-responders to infliximab: Adalimumab or ustekinumab (recommended) or vedolizumab (suggested) 1
• For secondary non-responders to adalimumab: Consider infliximab 1

Fistulizing Disease

• Infliximab has the most robust evidence for fistulizing disease 1
• Adalimumab, ustekinumab, and vedolizumab also show efficacy 1
• Certolizumab pegol may not be effective for induction in fistulizing disease 1

Phlegmon Management

• Combined approach of antibiotics and anti-TNF therapy is recommended 4
• Broad-spectrum antibiotics should be started immediately upon diagnosis 4

Common Pitfalls to Avoid

1. Using 5-ASA compounds inappropriately: Despite widespread use, 5-ASA compounds (except sulfasalazine for colonic disease) are not effective for Crohn's disease 1

2. Prolonged corticosteroid use: Corticosteroids should not be used for maintenance therapy due to significant side effects and lack of efficacy 1

3. Delaying effective therapy: Early introduction of biologics should be considered in high-risk patients rather than stepping through less effective therapies 1, 4

4. Inadequate monitoring: Regular assessment using objective markers (endoscopy, CRP, calprotectin) is essential for tight disease control 4

5. Overlooking combination therapy considerations: The potential benefits of combination therapy must be balanced against increased risk of adverse events, particularly in specific populations (elderly, young males) 1