What is the best course of treatment for a patient with a severe Crohn's flare, presenting with pancolitis, proctitis, and leukocytosis, who is already on steroids (corticosteroids) at home?

Management of Severe Crohn's Disease Flare with Pancolitis and Proctitis

For a patient with a severe Crohn's disease flare presenting with pancolitis, proctitis, and leukocytosis (WBC 24.6) who is already on steroids at home, intravenous corticosteroids (methylprednisolone 60 mg daily or hydrocortisone 100 mg every 6 hours) should be initiated immediately, with plans to escalate to anti-TNF therapy if no improvement occurs within 3-7 days.

Initial Management

1. Inpatient admission and IV corticosteroids:

   • Initiate IV methylprednisolone 60 mg daily or hydrocortisone 100 mg every 6 hours 1
   • Prophylactic low molecular weight heparin to prevent thromboembolism 1
   • Do not delay steroid treatment while awaiting stool cultures 1

2. Baseline investigations:

   • Stool cultures and C. difficile toxin assay
   • Blood tests: CBC, CRP, electrolytes, liver function, albumin
   • Flexible sigmoidoscopy (if not already done) to assess disease severity and obtain biopsies
   • Imaging: Consider CT abdomen if not already done to rule out complications

Monitoring Response

• Assess clinical response to IV steroids within 3-7 days 1
• Monitor vital signs, stool frequency, abdominal examination findings
• Track inflammatory markers (CRP, WBC)
• Maintain close surgical consultation throughout admission

Treatment Escalation Algorithm

If no improvement after 3-7 days of IV steroids:

1. Initiate anti-TNF therapy:

   • Infliximab 5 mg/kg IV at 0,2, and 6 weeks, then every 8 weeks 1, 2
   • Consider combination therapy with thiopurine (azathioprine or 6-mercaptopurine) for improved efficacy and pharmacokinetics 1
   • Screen for TB, hepatitis B/C, and HIV before starting biologics 2

2. Consider surgical consultation if:

   • Worsening symptoms despite medical therapy
   • Signs of toxic megacolon or perforation
   • Persistent high fever, tachycardia, or severe abdominal pain

Discharge Planning

When clinical improvement occurs:

• Transition to oral prednisone 40-60 mg daily with gradual taper over 8 weeks 1
• If anti-TNF therapy was initiated, continue maintenance schedule
• Consider adding thiopurine (azathioprine or 6-mercaptopurine) for maintenance therapy if not already started 1
• Schedule follow-up within 2-4 weeks of discharge

Important Considerations

• Avoid long-term corticosteroid use: Steroids are effective for induction but not for maintenance of remission 1, 3
• Monitor for steroid complications: Hyperglycemia, hypertension, electrolyte abnormalities
• Rule out infectious causes: Particularly C. difficile, which can mimic or exacerbate IBD flares 1
• Assess nutritional status: Consider nutritional support if malnourished 1

Pitfalls to Avoid

1. Delaying escalation of therapy when response to IV steroids is inadequate
2. Failing to screen for infections before intensifying immunosuppression
3. Not involving surgical team early in management
4. Prolonged use of corticosteroids for maintenance therapy
5. Inadequate thromboprophylaxis in this high-risk patient population

The evidence strongly supports early aggressive management with IV corticosteroids followed by prompt escalation to anti-TNF therapy if needed, as this approach has been shown to reduce morbidity and improve outcomes in patients with severe Crohn's disease flares.