What is the treatment for a Crohn's flare?

Treatment of Crohn's Disease Flares

For Crohn's disease flares, systemic corticosteroids are the recommended first-line treatment for inducing remission in moderate to severe disease, while budesonide is preferred for mild to moderate disease limited to the ileum and/or ascending colon. 1

Initial Assessment and Treatment Strategy

• Assess disease severity, location (ileal, ileocolonic, colonic), and pattern (inflammatory, stricturing, fistulating) before determining treatment approach 1
• Rule out complications such as abscess, stricture, or infection that may require specific interventions 1
• Consider biomarkers (fecal calprotectin >150 mg/g, elevated CRP) to confirm active inflammation 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate Disease Limited to Ileum/Ascending Colon:

• First-line: Budesonide 9 mg daily for 8 weeks (taper afterward) 1
  • Superior to placebo for inducing clinical response (RR: 1.46) and remission (RR: 1.93) 1
  • Better safety profile than systemic corticosteroids due to high topical activity and low systemic absorption 1

Moderate to Severe Disease:

• First-line: Systemic corticosteroids (prednisolone 40 mg daily or methylprednisolone) 1
  • Twice as effective as placebo for inducing remission (RR: 1.99) 1
  • Taper gradually over 8-12 weeks (typically 5 mg/week) to reduce risk of early relapse 1
• For severe disease requiring hospitalization: Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 1

Maintenance Therapy Following Flare Resolution

• Recommended: Early introduction of maintenance therapy while tapering corticosteroids 1
• Thiopurines (azathioprine, 6-mercaptopurine) are strongly recommended for steroid-dependent disease 1
• Methotrexate (at least 15 mg weekly, preferably subcutaneous) is an alternative maintenance option 1
• Biologic therapy (with or without immunomodulator) should be considered early rather than delaying after failure of corticosteroids, especially in high-risk patients 1
• Combination therapy of infliximab with a thiopurine is more effective than monotherapy for induction and maintenance of remission 1

Important Considerations and Cautions

• Do not use mesalazine (5-ASA) for treatment of Crohn's disease flares or maintenance - not effective according to current guidelines 1
• Monitor for steroid-related adverse effects (increased risk of abdominal/pelvic abscesses, Cushing syndrome, hypertension, diabetes, osteoporosis) 1
• Corticosteroids should NOT be used for maintenance therapy (strong recommendation) 1
• Consider concomitant antibiotics (metronidazole) if septic complications are suspected 1
• Surgical options should be considered for patients with stricturing or penetrating disease not responding to medical therapy 2

Special Situations

• For patients with perianal disease, additional specific treatments may be required 1
• In patients with severe disease not responding to intravenous steroids, consider early consultation with colorectal surgery 1
• For patients with frequent flares on maintenance therapy, consider optimization of current therapy or switching to a different class of medication 1

Remember that while corticosteroids are effective for inducing remission, they are not appropriate for long-term maintenance and early introduction of steroid-sparing maintenance therapy is essential to prevent future flares 1.