From the Guidelines
The first-line treatment for Crohn's disease without an acute flare is anti-TNF therapy, such as infliximab or adalimumab, as recommended by the most recent and highest quality study 1. This approach is based on the strong recommendation and moderate-quality evidence from the 2021 AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease 1.
Key Considerations
- The use of anti-TNF therapy is recommended over no treatment for induction and maintenance of remission in adult outpatients with moderate to severe Crohn's disease 1.
- The guidelines suggest against the use of natalizumab due to evidence of harm from progressive multifocal leukoencephalopathy (PML) and the availability of other drugs 1.
- For patients who are naïve to biologic drugs, the guidelines recommend the use of infliximab, adalimumab, or ustekinumab over certolizumab pegol for the induction of remission 1.
Treatment Approach
- Anti-TNF therapy, such as infliximab or adalimumab, should be used as first-line treatment for Crohn's disease without an acute flare, as it has been shown to be effective in inducing and maintaining remission 1.
- Lifestyle modifications, such as smoking cessation, stress management, and dietary adjustments, are also important in managing Crohn's disease.
- Regular follow-up appointments are essential to monitor disease activity and medication effectiveness.
Additional Considerations
- The use of thiopurines, such as azathioprine or 6-mercaptopurine, may be considered for maintenance therapy, but the evidence is conditional and of low quality 1.
- The guidelines suggest against the use of oral methotrexate for the induction and maintenance of remission due to very low-quality evidence 1.
From the FDA Drug Label
RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy
The first-line treatment for Crohn's disease without an acute flare is not specified in the label. The label indicates that RENFLEXIS is used for patients who have had an inadequate response to conventional therapy, implying that conventional therapy is typically tried first.
- Conventional therapy is not defined in the label, but it is implied to be the initial treatment approach.
- The label does not provide information on the specific treatment for Crohn's disease without an acute flare, as it focuses on the use of RENFLEXIS for moderately to severely active disease that has not responded to conventional therapy 2.
From the Research
First-Line Treatment for Crohn's Disease without an Acute Flare
The first-line treatment for Crohn's disease without an acute flare can vary depending on the severity and location of the disease.
- For patients with mildly active disease, high-dose mesalazine (mesalamine) or 5-aminosalicylic acid may be used 3.
- Azathioprine and mercaptopurine are considered first-line drugs for the maintenance of remission in moderate to severe Crohn's disease 3, 4.
- Exclusive enteral nutrition is recommended as the first line of treatment for the induction of remission in pediatric Crohn's disease 5.
- For adults, the treatment approach incorporates patient risk stratification, patient preference, and clinical factors in therapeutic decision-making, and may include steroids, monoclonal antibodies, immunomodulators, or surgery 6.
- Mesalamine products are often used for the medical management of mild to moderate colonic Crohn's disease 7.
Maintenance of Remission
The maintenance of remission in Crohn's disease is crucial to prevent long-term complications.
- Azathioprine, methotrexate, infliximab, and adalimumab have been shown to be effective for maintaining remission 3, 4, 5, 6.
- Long-term enteral nutritional supplementation may also be an effective strategy for maintaining remission in Crohn's disease 5.
- The choice of treatment for maintaining remission depends on the individual patient's disease severity, medical history, and response to previous treatments.