What are the main medications for Crohn's disease?

Main Medications for Crohn's Disease

The main medications for Crohn's disease include corticosteroids (budesonide, prednisolone), immunomodulators (thiopurines, methotrexate), and biologics (anti-TNF agents, vedolizumab, ustekinumab), with treatment selection based on disease severity, location, and pattern.

First-Line Treatments by Disease Severity and Location

Mild Disease

• Ileal/Ileocolonic Disease:

  • Budesonide 9 mg daily for 8 weeks is the preferred treatment for mild-to-moderate disease limited to the ileum and/or ascending colon 1
  • Evaluate response between 4-8 weeks
  • Benefits: High topical anti-inflammatory activity with low systemic absorption and fewer side effects than conventional steroids 2

• Colonic Disease:

  • Sulfasalazine 4 g daily may be effective specifically for mild colonic disease 2
  • Note: Other 5-ASA compounds (mesalamine) are NOT recommended due to lack of efficacy 2

Moderate-to-Severe Disease

• Systemic Corticosteroids:

  • Prednisolone 40-60 mg daily (tapered at 5 mg/week over 8-12 weeks) 2, 1
  • Twice as effective as placebo for inducing remission (RR: 1.99; 95% CI: 1.51-2.64) 2
  • Evaluate response between 2-4 weeks
  • Not suitable for maintenance therapy due to side effects 1

• Biologics:

  1. Anti-TNF agents (infliximab, adalimumab)

     • First-line biologics for moderate-to-severe disease 2
     • Particularly effective for perianal fistulizing disease 2

  2. Vedolizumab (gut-selective anti-integrin)

     • Alternative for patients with contraindications to anti-TNF therapy 2, 1

  3. Ustekinumab (anti-IL-12/23)

     • Effective for induction and maintenance 2

Maintenance Therapy

• Thiopurines:

  • Azathioprine (1.5-2.5 mg/kg/day) or 6-mercaptopurine (0.75-1.5 mg/kg/day) 1
  • Particularly important for steroid-dependent patients 2, 1
  • Not effective for rapid induction of remission 1

• Methotrexate:

  • 15-25 mg weekly (preferably parenteral) 1
  • Alternative for patients who cannot tolerate thiopurines 1

• Biologics:

  • Continue the same biologic that induced remission 1
  • May be combined with immunomodulators in high-risk patients 1

Special Considerations

Perianal Fistulizing Disease

• Infliximab is strongly recommended over no treatment for induction and maintenance of fistula remission 2
• Adalimumab, ustekinumab, or vedolizumab are conditionally recommended as alternatives 2
• Antibiotics alone are not recommended for fistula remission 2

Combination Therapy

• When using infliximab, combination with methotrexate may improve pharmacokinetics and reduce immunogenicity 3
• Patients on immunosuppressants tend to experience fewer infusion reactions with infliximab 3

Treatments NOT Recommended

• 5-ASA compounds (except sulfasalazine for mild colonic disease) are not recommended for induction or maintenance of remission in moderate-to-severe CD 2, 1
• Systemically absorbed antibiotics are not recommended for luminal CD 2, 1
• Corticosteroids should not be used for maintenance therapy 1
• Marijuana, naltrexone, enteral nutrition, or dietary modification are not recommended for induction or maintenance of remission 2

Monitoring and Management

• Regular assessment of disease activity using objective markers (endoscopy, CRP, calprotectin)
• Laboratory monitoring specific to each medication
• For patients on corticosteroids: prophylactic calcium and vitamin D to prevent osteoporosis 1
• Monitor for drug-specific adverse effects and adjust therapy as needed

Common Pitfalls to Avoid

1. Using 5-ASA compounds (except sulfasalazine for mild colonic disease) which lack efficacy in CD
2. Prolonged corticosteroid use without a steroid-sparing strategy
3. Delaying appropriate therapy in high-risk patients
4. Failing to monitor for medication side effects
5. Not considering disease location when selecting therapy (e.g., budesonide is only effective for ileal/ileocolonic disease)
6. Using antibiotics for luminal disease outside of septic complications

By following this evidence-based approach to medication selection, patients with Crohn's disease can achieve optimal outcomes with reduced morbidity and improved quality of life.