What is the medical management of Crohn's disease?

From the Guidelines

The medical management of Crohn's disease involves a stepwise approach based on disease severity and location, with biologic agents such as anti-TNF medications (infliximab, adalimumab), anti-integrin therapy (vedolizumab), or IL-12/23 inhibitors (ustekinumab) recommended for moderate to severe disease or when other treatments fail, as supported by the most recent and highest quality study 1.

Key Considerations

• Initial treatment typically includes anti-inflammatory medications such as aminosalicylates for mild disease, though these are more effective for ulcerative colitis.
• Corticosteroids like prednisone or budesonide are used for moderate flares to rapidly induce remission but aren't suitable for long-term use due to side effects.
• For maintenance therapy, immunomodulators are often prescribed, including azathioprine, 6-mercaptopurine, or methotrexate.
• Treatment should be individualized based on disease phenotype, severity, complications, and patient factors, with regular monitoring for medication efficacy and adverse effects.

Medication Options

• Anti-TNF medications: infliximab 5mg/kg IV at weeks 0,2,6, then every 8 weeks; adalimumab 160mg initially, 80mg at week 2, then 40mg every 2 weeks.
• Anti-integrin therapy: vedolizumab.
• IL-12/23 inhibitors: ustekinumab.

Supporting Evidence

• The AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease recommend the use of anti-TNF therapy as first-line therapy to induce complete remission in patients with moderate to severe luminal Crohn's disease with risk factors of poor prognosis 1.
• The ECCO guidelines on therapeutics in Crohn's disease: medical treatment suggest the use of biologic agents such as anti-TNF medications, anti-integrin therapy, or IL-12/23 inhibitors for moderate to severe disease or when other treatments fail 1.

From the FDA Drug Label

RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adults with moderately to severely active Crohn's disease or fistulizing Crohn's disease

The medical management of Crohn's disease with infliximab (IV) includes:

• Induction regimen: 5 mg/kg at 0,2, and 6 weeks
• Maintenance regimen: 5 mg/kg every 8 weeks
• Dose adjustment: Consideration may be given to treatment with 10 mg/kg for adult patients who respond and then lose their response
• Discontinuation: Patients who do not respond by Week 14 are unlikely to respond with continued dosing and consideration should be given to discontinue RENFLEXIS in these patients 2

From the Research

Medical Management of Crohn's Disease

The medical management of Crohn's disease involves several treatment options, including:

• Conventional therapeutics such as 5-aminosalicylic acid, corticosteroids, purine analogs, azathioprine, and 6-mercaptopurine 3
• Tumor necrosis factor (TNF)-α inhibitors such as infliximab and adalimumab for patients who fail to respond to conventional therapy 3
• Combination therapy with TNF-α blockade plus azathioprine or granulocyte and monocyte adsorptive apheresis for patients who do not respond to TNF-α inhibitors 3
• Neutralizing antibodies directed against integrin α4 and α4β7, such as natalizumab and vedolizumab 3
• Neutralizing antibodies directed against the receptors for interleukin-12 and interleukin-23, such as ustekinumab 3

Treatment Approaches

There are two main treatment approaches for Crohn's disease:

• Step-up approach: starts with mild treatments and gradually increases to more aggressive treatments as needed 4, 5
• Top-down approach: starts with more aggressive treatments, such as biologics and immunomodulators, to reduce the rate of mucosal and intestinal damage 6, 5, 7 The top-down approach has been shown to result in more rapid and higher rates of mucosal healing and has the potential to modify the natural course of the disease 5, 7

Factors to Consider

When selecting a treatment strategy for Crohn's disease, several factors should be considered, including:

• Age stratification 7
• Disease location and extension 7
• Genetic and serologic testing 7
• Predictors of disease progression and complication 7 These factors can help guide a personalized treatment approach and determine the most suitable treatment strategy for each patient.