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

Treatment of Crohn's Disease Flare

For Crohn's disease flares, 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

Treatment Algorithm Based on Disease Severity and Location

Mild-to-Moderate Disease

1. Ileal/Ileocolonic Disease Limited to Ascending Colon:

   • First-line: Budesonide 9 mg daily for 8 weeks 2, 1
   • Evaluate response between 4-8 weeks 1
   • Budesonide has high topical anti-inflammatory activity with low systemic absorption, resulting in fewer side effects compared to conventional steroids 2

2. Colonic Disease:

   • Sulfasalazine may be considered for mild colonic disease, though evidence is limited 1
   • Note: Regular 5-ASA (mesalamine) is not recommended for Crohn's disease as it shows no significant effect for induction of remission 2, 1

Moderate-to-Severe Disease

1. Systemic Corticosteroids:

   • First-line: Oral prednisolone 40-60 mg daily (tapered at 5 mg/week over 8-12 weeks) 2, 1
   • For hospitalized patients: IV methylprednisolone 40-60 mg daily 1
   • Evaluate response between 2-4 weeks for oral therapy and within 1 week for IV therapy 1
   • Corticosteroids are twice as effective as placebo in inducing remission (RR: 1.99; 95% CI: 1.51–2.64) 2

2. For Inadequate Response to Corticosteroids:

   • Consider early biological therapy 1
   • Anti-TNF agents (infliximab, adalimumab, certolizumab) are effective options 1, 3
   • Adalimumab dosing for Crohn's disease: 160 mg initially on Day 1, followed by 80 mg two weeks later, then 40 mg every other week starting at Day 29 3

Important Considerations and Cautions

Medications NOT Recommended for Flares

• 5-ASA compounds (except sulfasalazine for mild colonic disease): Meta-analysis showed no significant effect for induction of remission (RR: 1.28; 95% CI: 0.97–1.69) 2, 4
• Thiopurines (azathioprine, 6-mercaptopurine): Not recommended as monotherapy for induction of remission 2, 1
• Antibiotics: Not recommended for luminal Crohn's disease (though indicated for septic complications) 2

Monitoring and Side Effects

• Corticosteroid side effects: Cushing syndrome, acne, increased infection risk (particularly abdominal/pelvic abscesses), hypertension, diabetes, osteoporosis, cataracts, glaucoma 2
• Prophylactic measures: Calcium and vitamin D supplementation for patients on corticosteroids to prevent osteoporosis 1
• Monitoring: Regular assessment of disease activity using objective markers (endoscopy, CRP, calprotectin) 2, 1

Maintenance Therapy After Flare Resolution

• Thiopurines: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) for maintenance, especially for steroid-dependent patients 1
• Methotrexate: 15-25 mg weekly (preferably parenteral) for patients who cannot tolerate thiopurines 1
• Biologics: Continue the same biologic that induced remission 1

Special Populations and Situations

• High-risk patients (extensive disease, poor prognostic factors): Consider early biological therapy, potentially combined with immunomodulators 1
• Steroid-dependent patients: Thiopurines or methotrexate are recommended for maintenance 1
• Anti-TNF failures: Consider ustekinumab or vedolizumab 1

Remember that smoking cessation is strongly recommended as smoking worsens Crohn's disease 1. Additionally, nutritional deficiencies should be corrected as part of comprehensive management.