What is the treatment for an active Crohn's disease flare-up?

Treatment of Active Crohn's Disease Flare-Up

For an active Crohn's disease flare-up, systemic corticosteroids are the recommended first-line treatment for moderate to severely active disease, while biologics should be considered early for patients with poor prognostic features or extensive disease. 1

Initial Assessment and Treatment Selection

Treatment should be tailored based on:

• Disease severity (mild, moderate, severe)
• Disease location (ileal, ileocolonic, colonic)
• Disease pattern (inflammatory, stricturing, fistulating)
• Previous treatment response

First-Line Treatments

Mild to Moderate Disease:

• Ileal/Ileocolonic Disease:
  • High-dose mesalazine (4g/day) may be sufficient for mild disease 1
  • Budesonide 9mg daily for isolated ileo-cecal disease 1
  • Oral prednisolone 40mg daily for moderate disease 1

Moderate to Severe Disease:

• Oral corticosteroids: Prednisolone 40mg daily with gradual taper over 8 weeks 1
• Intravenous steroids: Hydrocortisone 400mg/day or methylprednisolone 60mg/day for severe disease 1
  • Consider concomitant IV metronidazole to rule out septic complications 1

Perianal/Fistulating Disease:

• Metronidazole 400mg three times daily and/or ciprofloxacin 500mg twice daily 1
• Consider surgical drainage for abscesses
• For complex fistulae, combination of antibiotics, immunomodulators, and anti-TNF therapy 1

Second-Line and Advanced Therapies

For patients who fail to respond to initial therapy:

Immunomodulators:

• Thiopurines: Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day)
  • Not for acute flares due to slow onset of action 1
  • Useful as steroid-sparing agents and maintenance therapy 1

Biologics:

• Anti-TNF agents: (For moderate-severe disease with risk factors or failing conventional therapy)

  • Infliximab: 5mg/kg at weeks 0,2, and 6, then every 8 weeks 1
  • Adalimumab: 160mg initially, 80mg at week 2, then 40mg every other week 2
  • Combination with thiopurine is more effective than monotherapy 1

• Other biologics: (For anti-TNF failures)

  • Vedolizumab: 300mg at weeks 0,2, and 6, then every 8 weeks 1
  • Ustekinumab: Weight-based IV induction, then SC maintenance 1

Nutritional Support

• Elemental or polymeric diets can be used as adjunctive therapy 1
• Total parenteral nutrition is appropriate for complex, fistulating disease 1
• Consider as primary therapy in patients with contraindications to corticosteroids 1

Monitoring Response

• Evaluate response to anti-TNF induction therapy between 8-12 weeks 1
• Assess response to IV corticosteroids within 1 week 1
• If no improvement with thiopurines or methotrexate within 12-16 weeks, modify therapy 1

Important Considerations

• Avoid maintenance corticosteroids: Not effective for maintaining remission and associated with significant side effects 1
• Avoid 5-ASA for maintenance: Not effective for maintaining remission in Crohn's disease 1
• Antibiotics: Metronidazole (10-20mg/kg/day) may be appropriate for colonic or treatment-resistant disease 1
• Surgery: Consider for patients who have failed medical therapy or for limited ileal/ileocecal disease 1

Treatment Pitfalls to Avoid

1. Delayed escalation of therapy: Early aggressive treatment may prevent complications in high-risk patients
2. Overuse of corticosteroids: Associated with significant side effects and not effective for maintenance
3. Monotherapy with thiopurines for acute flares: Too slow-acting to be effective
4. Inadequate dosing of biologics: Therapeutic drug monitoring should guide dose optimization
5. Failure to consider combination therapy: Anti-TNF plus immunomodulator is more effective than monotherapy alone

Remember that achieving and maintaining deep remission is crucial for preventing disease progression and complications, though recent evidence suggests even steroid-free deep remission at one year may not prevent long-term disease progression 3.