What is the treatment for a Crohn's (Crohn's disease) flare-up?

Treatment for Crohn's Disease Flare-Up

For Crohn's disease flare-ups, systemic corticosteroids are recommended for moderate-to-severe disease, while budesonide 9 mg daily is the preferred treatment for mild-to-moderate disease limited to the ileum and/or ascending colon. 1, 2

Treatment Algorithm Based on Disease Severity

Mild-to-Moderate Disease

1. Location-specific treatment:

   • Ileal/Ileocolonic disease (limited to ascending colon): Budesonide 9 mg daily for 8 weeks 1, 2
   • Colonic disease: Consider sulfasalazine (though evidence is limited) 1

2. Evaluation of response:

   • Assess response to budesonide between 4-8 weeks 2
   • If inadequate response, escalate to systemic corticosteroids

3. Avoid ineffective treatments:

   • 5-ASA compounds (mesalamine) are not recommended for small bowel Crohn's disease 1, 2, 3
   • Antibiotics are not recommended unless septic complications are suspected 2

Moderate-to-Severe Disease

1. Initial treatment:

   • Systemic corticosteroids: Prednisolone 40-60 mg daily orally or methylprednisolone 40-60 mg daily IV for hospitalized patients 1, 2

2. Evaluation of response:

   • Assess response within 1-2 weeks for IV corticosteroids 2
   • Assess response within 2-4 weeks for oral prednisone 2

3. Corticosteroid taper:

   • Plan taper over 8-12 weeks once response is achieved 2
   • Initiate maintenance therapy to prevent relapse and steroid dependence

Maintenance Therapy After Flare Resolution

1. First-line maintenance options:

   • Thiopurines: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1, 2
   • Particularly important for steroid-dependent patients 1

2. Alternative maintenance options:

   • Methotrexate (15-25 mg weekly, preferably parenteral) for patients who cannot tolerate thiopurines 2

3. Biological therapy considerations:

   • Consider early biological therapy for patients with extensive disease or poor prognostic factors 2
   • Anti-TNF agents (infliximab, adalimumab, certolizumab) for patients with inadequate response to corticosteroids 2, 4
   • Ustekinumab or vedolizumab for patients who fail anti-TNF therapy 1

Important Considerations and Precautions

1. Monitoring during treatment:

   • Regular assessment of clinical response
   • Laboratory monitoring specific to each medication 2
   • Watch for complications of both disease and treatments

2. Corticosteroid precautions:

   • Not suitable for maintenance therapy due to significant side effects 2
   • Consider prophylactic calcium and vitamin D to prevent osteoporosis 2
   • Monitor for cushingoid features, hypertension, hyperglycemia, and mood changes 1

3. Biological therapy precautions:

   • Increased risk of serious infections and potential malignancy 4
   • Screen for tuberculosis and other infections before initiating therapy 4
   • Consider combination with immunomodulator for improved efficacy but with increased risk of complications 1, 2

Special Situations

1. Fistulizing disease:

   • Anti-TNF therapy (infliximab 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) 4

2. Steroid-dependent disease:

   • Thiopurines are strongly recommended 1
   • Consider early biological therapy 1, 2

3. Surgical considerations:

   • Consider for strictures >5 cm or when medical therapy fails 2
   • Endoscopic balloon dilation for short (<5 cm) strictures 2

The treatment approach should be guided by disease severity, location, and individual risk factors, with the goal of inducing and maintaining remission while minimizing complications and improving quality of life.