What is the recommended treatment for a 45-year-old male with Crohn's disease?

Treatment Recommendations for a 45-Year-Old Male with Crohn's Disease

For a 45-year-old male with Crohn's disease, anti-TNF therapy (infliximab or adalimumab) combined with a thiopurine is strongly recommended as first-line treatment for moderate to severe disease to achieve and maintain remission, while budesonide is recommended for mild to moderate disease limited to the ileum or right colon.

Initial Assessment and Disease Severity Classification

Before initiating treatment, determine disease severity:

• Mild to moderate disease: Ambulatory patients with no systemic symptoms, able to tolerate oral intake, no dehydration, no abdominal tenderness, mass, or obstruction
• Moderate to severe disease: Failed to respond to treatment for mild disease, or have fever, weight loss >10%, abdominal pain, nausea/vomiting, or anemia

Treatment Algorithm Based on Disease Severity

For Mild to Moderate Disease

1. Ileal or Right Colonic Disease:

   • First-line: Oral budesonide 9 mg/day for induction of remission 1
   • Evaluate response within 4-8 weeks 1
   • Note: Budesonide should not be used for maintenance therapy 1

2. Colonic Disease Only:

   • First-line: Sulfasalazine 4-6 g/day for induction 1
   • Evaluate response within 2-4 months 1
   • Note: 5-ASA agents are not recommended for non-colonic disease 1

For Moderate to Severe Disease

1. First-line Treatment:

   • Anti-TNF therapy + thiopurine combination 1, 2
     • Infliximab: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 2
     • Adalimumab: 160 mg initially (Day 1), 80 mg at week 2 (Day 15), then 40 mg every other week starting at week 4 (Day 29) 3
   • Combination with azathioprine or 6-mercaptopurine is recommended for better efficacy 1, 2

2. Alternative First-line Options (if anti-TNF contraindicated):

   • Ustekinumab: Strongly recommended by AGA 1, 2
   • Vedolizumab: Conditionally recommended, especially for patients with safety concerns about systemic immunosuppression 1, 2

3. For Anti-TNF Primary Non-responders:

   • First choice: Ustekinumab 2
   • Second choice: Vedolizumab 2

Maintenance Therapy

1. After Achieving Remission with Anti-TNF:

   • Continue anti-TNF therapy for maintenance 1
   • For patients on combination therapy, continue both anti-TNF and immunomodulator 2

2. After Corticosteroid-Induced Remission:

   • Thiopurine monotherapy (azathioprine or 6-mercaptopurine) 1, 2
   • Parenteral methotrexate if remission achieved with corticosteroids and methotrexate 1

Monitoring and Optimization

1. Evaluate Response to Therapy:

   • Anti-TNF therapy: Assess between 8-12 weeks 1, 2
   • Thiopurines/methotrexate: Assess at 12-16 weeks 1
   • If inadequate response to anti-TNF, consider dose intensification 1

2. Therapeutic Drug Monitoring:

   • Recommended for optimizing anti-TNF therapy in patients with loss of response 1

Important Considerations

• Corticosteroids (prednisone 40-60 mg/day) should only be used for short-term induction of remission and not for maintenance 1
• Avoid 5-ASA agents except for sulfasalazine in colonic disease 1
• Antibiotics are not recommended for induction or maintenance of remission 1
• Safety monitoring is essential, particularly for combination therapy (anti-TNF + thiopurine), which carries an increased risk of lymphoma, especially in young males 2

Prescription for Adalimumab (for moderate-severe disease)

• Medication: Adalimumab (Humira) subcutaneous injection
• Induction: 160 mg on Day 1 (given as 4 injections of 40 mg in one day or split over two consecutive days), followed by 80 mg two weeks later (Day 15)
• Maintenance: 40 mg every other week starting at week 4 (Day 29)
• Concomitant therapy: Consider adding azathioprine 2-2.5 mg/kg/day if no contraindications
• Monitoring: Evaluate response at 8-12 weeks; assess for absence of abdominal pain/tenderness, normalization of stool frequency, and ability to taper corticosteroids if applicable

This treatment approach prioritizes achieving and maintaining remission while minimizing disease progression and improving quality of life in this 45-year-old male with Crohn's disease.