What is the treatment for Crohn's disease?

Treatment of Crohn's Disease

The treatment of Crohn's disease should follow a stepwise approach based on disease severity, location, and complications, with biologic agents such as anti-TNF therapies being the cornerstone for moderate-to-severe disease. 1

Disease Assessment and Treatment Strategy

Treatment selection depends on several key factors:

• Disease severity (mild, moderate, severe)
• Disease location (ileal, ileocolonic, colonic, perianal)
• Disease behavior (inflammatory, stricturing, penetrating)
• Previous response to therapy
• Presence of complications

Mild-to-Moderate Disease

Ileal/Ileocolonic Disease:

• First-line: Budesonide 9 mg daily for 8 weeks 1
  • Preferred due to high topical anti-inflammatory activity and low systemic absorption
  • Not suitable for long-term use due to steroid-related side effects

Colonic Disease:

• First-line: Sulfasalazine 4 g daily 1
  • Note: Other 5-ASA compounds lack proven efficacy in Crohn's disease except for mild colonic disease 1

Moderate-to-Severe Disease

• First-line: Prednisolone 40-60 mg daily (tapered at 5 mg/week over 8-12 weeks) 1

  • Twice as effective as placebo for inducing remission
  • Not suitable for maintenance therapy due to significant side effects

• Maintenance therapy (after steroid induction):

  • Thiopurines: Azathioprine (1.5-2.5 mg/kg/day) or 6-mercaptopurine (0.75-1.5 mg/kg/day) 1
  • Methotrexate: 15-25 mg weekly (preferably parenteral) for patients who cannot tolerate thiopurines 1

Severe or Refractory Disease

• Biologic agents:

  • Anti-TNF agents (first-line biologics): 1, 2, 3

    • Infliximab: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 2
    • Adalimumab: 160 mg SQ initially (day 1), 80 mg at week 2, then 40 mg every other week 3
    • Particularly effective for perianal fistulizing disease

  • Vedolizumab: Alternative for patients with contraindications to anti-TNF therapy 1

  • Ustekinumab: Effective for induction and maintenance 1

Special Considerations

Perianal Fistulizing Disease

• Anti-TNF agents (infliximab or adalimumab) are the most effective medical therapy 1, 2
• Often combined with antibiotics and/or thiopurines

Steroid-Dependent Disease

• Thiopurines or methotrexate are recommended for steroid-sparing 1
• Early introduction of biologics should be considered

High-Risk Patients

• Early introduction of biologics, potentially combined with immunomodulators 1
• Regular monitoring of disease activity using objective markers (endoscopy, CRP, calprotectin) 1

Monitoring and Adjustments

• Regular assessment of disease activity using objective markers is essential 1
• Laboratory monitoring specific to each medication is necessary
• Prophylactic calcium and vitamin D for patients on corticosteroids 1
• Monitor for drug-specific adverse effects:
  • Anti-TNF agents: serious infections, tuberculosis reactivation 2, 3
  • Thiopurines: bone marrow suppression, hepatotoxicity, pancreatitis
  • Methotrexate: hepatotoxicity, pneumonitis

Common Pitfalls to Avoid

• Using 5-ASA compounds (except sulfasalazine for mild colonic disease) 1, 4
• Prolonged corticosteroid use without a steroid-sparing strategy 1
• Delaying appropriate therapy in high-risk patients 1
• Failing to monitor for medication side effects 1
• Using antibiotics for luminal disease outside of septic complications 1
• Using corticosteroids for maintenance therapy 1

Medication Safety Considerations

• Anti-TNF agents: Screen for tuberculosis and hepatitis B before initiation; monitor for serious infections 2, 3
• Thiopurines: Risk of lymphoma, especially when combined with anti-TNF agents in young males 2
• Corticosteroids: Significant side effects including Cushing syndrome, increased infection risk, hypertension, diabetes, osteoporosis 1

Remember that treatment goals should focus on inducing and maintaining clinical remission, mucosal healing, and improving quality of life while minimizing complications and medication side effects.