What are the treatment options for a Crohn's disease flare-up?

Treatment Options for Crohn's Disease Flare-Ups

For moderate to severely active Crohn's disease flare-ups, systemic corticosteroids are the first-line treatment, while biological therapies should be considered early for patients with extensive disease or poor prognostic factors.

Initial Treatment Options Based on Disease Severity

Mild to Moderate Flare with Ileal/Right Colonic Involvement

• Budesonide 9 mg/day for localized ileal or right colonic disease 1
  • Superior response compared to placebo with fewer systemic side effects than conventional steroids
  • Evaluate response within 4-8 weeks 1

Moderate to Severe Flare

• Systemic corticosteroids (prednisolone 40-60 mg/day orally or methylprednisolone 40-60 mg/day IV for hospitalized patients) 2, 1
  • Evaluate response within 1-2 weeks 1
  • Plan taper over 8-12 weeks 1
  • Not suitable for maintenance therapy due to side effects 2, 1

Biological Therapy Options for Inadequate Response to Steroids

When patients have inadequate response to corticosteroids or have high-risk features:

1. Anti-TNF agents (infliximab, adalimumab, certolizumab) 1, 3

   • Infliximab: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 3
   • Consider combination with immunomodulator for improved efficacy 1

2. Ustekinumab 2, 1

   • Effective for both induction and maintenance
   • 51% clinical remission rate at 44 weeks compared to 35.9% with placebo 2
   • Can be administered every 8 or 12 weeks for maintenance 2

3. Vedolizumab 2, 1

   • 300 mg IV every 8 weeks for maintenance
   • 39% clinical remission at week 52 versus 21.6% with placebo 2

Maintenance Therapy After Flare Resolution

Corticosteroids should never be used for maintenance therapy 2, 1. Instead:

1. Thiopurines (azathioprine or mercaptopurine) 2

   • First-line maintenance option after steroid-induced remission
   • Particularly important for patients with adverse prognostic factors (early age of onset, perianal disease, steroid use at presentation) 2

2. Methotrexate 2

   • Consider for patients who cannot tolerate thiopurines
   • Administered parenterally (15 mg weekly) 2
   • 65% remained in remission at 40 weeks versus 39% with placebo 2

3. Continue the same biologic that induced remission 2

   • Strong recommendation with moderate evidence quality

Management of Strictures

For patients with stricturing disease:

• Endoscopic balloon dilation for short (<5 cm) strictures 2

  • Technical success rate of 89-90% 2
  • Clinical success rate of 70-80% 2
  • Complications (perforation/bleeding) occur in 2.8-6.4% of procedures 2

• Surgical intervention when appropriate 2

  • Consider for strictures >5 cm or when balloon dilation fails
  • Deferred surgery is preferred for acute small-bowel obstruction without ischemia or peritonitis 2

Important Considerations and Monitoring

• Avoid smoking as it worsens Crohn's disease 2
• Monitor for complications of both disease and treatments:
  • Infection risk with biologics and immunosuppressants 3
  • Malignancy risk, particularly with combination therapy 3
  • Osteoporosis with corticosteroid use (provide calcium and vitamin D) 1
• Laboratory monitoring per guidelines for each medication 2
• Assess response to therapy at appropriate intervals 1

Treatment Algorithm for Crohn's Disease Flare

1. Assess severity and location of disease
2. Initiate induction therapy:
   • Mild-moderate ileal/right colonic: Budesonide
   • Moderate-severe or extensive: Systemic corticosteroids
   • Poor prognostic factors or severe disease: Consider early biologics
3. Evaluate response within 1-2 weeks for IV steroids, 2-4 weeks for oral steroids
4. If inadequate response: Escalate to biological therapy
5. Plan maintenance strategy before steroid taper is complete
6. Monitor for complications and adjust therapy as needed