What medication is recommended for a 66-year-old male with distal ileal ulcers causing anemia due to Crohn's disease, with a mildly elevated fecal calprotectin (FC) level?

Treatment for 66-Year-Old Male with Distal Ileal Ulcers Causing Anemia in Crohn's Disease

For a 66-year-old male with distal ileal ulcers causing anemia due to Crohn's disease with a fecal calprotectin of 35, adalimumab is the recommended medication to effectively treat both the ileal inflammation and resulting anemia.

Assessment of Disease Activity

• A fecal calprotectin level of 35 μg/g is below the standard cutoff of 150 μg/g, suggesting minimal active inflammation, though this doesn't rule out the presence of distal ileal ulcers 1
• Low fecal calprotectin (<50 μg/g) has a high negative predictive value (94.1%) for small bowel inflammation, but the presence of anemia indicates ongoing disease activity despite the low biomarker 2
• The presence of anemia with ileal ulcers indicates moderate to severe disease requiring effective treatment, regardless of the relatively low fecal calprotectin value 1

Treatment Recommendations

First-Line Therapy

• Adalimumab (Humira) is indicated for the treatment of moderately to severely active Crohn's disease in adults and is the recommended first-line therapy for this patient 3
• The standard induction dosing for Crohn's disease is:
  • 160 mg on Day 1 (given in one day or split over two consecutive days)
  • 80 mg on Day 15
  • 40 mg every other week starting on Day 29 3

Rationale for Adalimumab Selection

• TNF inhibitors like adalimumab are effective for treating both luminal inflammation and anemia in Crohn's disease 3
• Adalimumab has demonstrated efficacy in healing ileal ulcers and improving hemoglobin levels in patients with Crohn's disease 3
• The presence of anemia with ulceration indicates a more severe disease course requiring biologic therapy rather than just mesalamine-based treatments 1

Monitoring Approach

• Repeat fecal calprotectin measurement in 2-4 months after initiating therapy to assess treatment response 1
• Target normalization of fecal calprotectin within 12 months of treatment, as this is associated with reduced risk of disease progression (HR 0.36; 95% CI, 0.24-0.53) 4
• Monitor hemoglobin levels to assess improvement in anemia 1
• Consider endoscopic assessment 6-12 months after treatment initiation to confirm mucosal healing 1

Important Considerations and Precautions

• Prior to initiating adalimumab, perform testing for latent tuberculosis; if positive, start TB treatment before starting adalimumab 3
• Monitor for serious infections, as TNF inhibitors increase the risk of bacterial, fungal, and opportunistic infections 3
• Be aware of potential malignancy risks associated with TNF inhibitors, particularly lymphoma 3
• Consider hepatitis B screening before initiating therapy, as reactivation can occur 3

Alternative Approaches

• For patients who cannot tolerate or have contraindications to adalimumab, consider other biologic options such as:
  • Other TNF inhibitors (infliximab)
  • IL-12/23 inhibitors (ustekinumab)
  • Integrin inhibitors (vedolizumab) 1
• Mesalamine-based therapies alone are likely insufficient for treating ileal ulcers causing anemia, though they may be used as adjunctive therapy 5, 6

Importance of Treating to Target

• Normalization of inflammatory markers and healing of mucosal ulceration should be the treatment goals 4
• Patients who normalize fecal calprotectin within 12 months of diagnosis have significantly lower risk of disease progression, hospitalization, and surgery 4
• Even in asymptomatic patients, elevated inflammatory markers warrant treatment adjustment to prevent disease progression 7