What is the treatment for Crohn's disease?

Treatment of Crohn's Disease

The treatment of Crohn's disease requires a step-wise approach with biologic therapy (anti-TNF agents, anti-integrins, or anti-IL-12/23) recommended as the cornerstone for moderate-to-severe disease, while budesonide or systemic corticosteroids are first-line for mild-to-moderate disease. 1

Initial Assessment and Treatment Strategy

Mild-to-Moderate Disease

• First-line therapy:
  • Budesonide 9 mg daily for 8 weeks is preferred for mild-to-moderate ileal or ileocolonic disease due to better safety profile 1
  • Systemic corticosteroids (prednisolone 40-60 mg daily) for disease in other locations 1
  • Evaluate response between 4-8 weeks for budesonide and 2-4 weeks for systemic corticosteroids

Moderate-to-Severe Disease

• First-line therapy:
  • Biologic agents with or without immunomodulators 1
  • Options include:
    • TNF-α inhibitors (infliximab, adalimumab)
    • IL-12/23 inhibitors (ustekinumab)
    • Anti-integrin agents (vedolizumab)

Specific Medication Regimens

Corticosteroids

• Budesonide: 9 mg daily for 8 weeks for mild-to-moderate ileal/ileocolonic disease 1
• Prednisolone: 40-60 mg daily with taper at 5 mg/week over 8-12 weeks 1
• Intravenous steroids: For severe disease - hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1

Biologic Agents

Infliximab 2

• Dosing: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks
• For inadequate responders: May increase to 10 mg/kg
• Discontinuation: Consider if no response by week 14

Adalimumab 3

• Induction: 160 mg on day 1 (given in one day or split over two consecutive days), 80 mg on day 15
• Maintenance: 40 mg every other week starting on day 29

Immunomodulators

• Azathioprine: 1.5-2.5 mg/kg/day for maintenance therapy 1
• Mercaptopurine: 0.75-1.5 mg/kg/day for maintenance therapy 1
• Methotrexate: 15-25 mg weekly (preferably parenteral) as alternative maintenance option 1

Management of Complications

Fistulizing Disease

• Antibiotics: Metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily 1
• Anti-TNF therapy: Particularly infliximab for complex fistulae 1
• Surgical consultation: For drainage of abscesses or seton placement 1

Monitoring and Follow-up

• Regular assessment using objective markers:
  • Laboratory markers (CRP, ESR)
  • Fecal calprotectin
  • Endoscopic evaluation to assess mucosal healing 1

Important Considerations and Pitfalls

Avoid These Common Mistakes

1. Using corticosteroids for maintenance therapy - significant side effects including Cushing syndrome, increased infection risk, hypertension, diabetes, osteoporosis 1
2. Using 5-ASA compounds for Crohn's disease - European Crohn's and Colitis Organisation recommends against this 1
3. Delaying escalation of therapy - can lead to inadequate response 1
4. Overlooking complications such as abscess, stricture, or perforation 1

Special Precautions

• Screen for tuberculosis and other infections before initiating biologic therapy 1
• Combination therapy with a TNF inhibitor and an immunomodulator may improve efficacy but increases risk of infections 1
• Pregnancy and infection require special consideration 1
• Smoking cessation is strongly recommended as smoking worsens Crohn's disease 1

Safety Warnings

• Serious infections may occur with biologic therapies, especially when combined with immunosuppressants 2, 3
• Malignancy risk including lymphoma has been reported with TNF blockers 2, 3
• Hepatosplenic T-cell lymphoma has been reported, particularly in young males with inflammatory bowel disease on combination therapy with azathioprine/6-mercaptopurine and TNF blockers 2, 3

The treatment approach should be guided by disease severity, location, and individual risk factors for progression, with the goal of achieving and maintaining remission while minimizing complications and improving quality of life 4, 1.