What is the initial treatment for Crohn's disease?

Initial Treatment for Crohn's Disease

For patients with mild to moderate Crohn's disease, oral budesonide at 9 mg/day is recommended as first-line therapy for induction of remission in those with ileal and/or right colonic disease, while sulfasalazine at 4-6 g/day may be used for mild disease limited to the colon. 1

Treatment Based on Disease Severity and Location

Mild to Moderate Ileal/Right Colonic Disease

• Oral budesonide 9 mg/day is the preferred first-line therapy for induction of remission 1
• Evaluate response to budesonide between 4-8 weeks to determine need for therapy modification 1
• Budesonide should not be used for maintenance therapy beyond 12 weeks due to lack of efficacy 1
• Budesonide has fewer adverse events compared to conventional corticosteroids while maintaining efficacy 1

Mild Colonic Disease

• Sulfasalazine 4-6 g/day is suggested for induction of remission 1
• Evaluate response to sulfasalazine between 2-4 months 1
• Sulfasalazine appears more effective for colonic disease than other locations 1

Moderate to Severe Disease

• Prednisone 40-60 mg/day is recommended for induction of remission in moderate to severe disease or for those who fail budesonide 1
• Evaluate response to prednisone between 2-4 weeks 1
• For hospitalized patients with severe disease, intravenous corticosteroids (methylprednisolone 40-60 mg/day) are suggested 1

Important Considerations for Corticosteroid Use

• Corticosteroids should NOT be used for maintenance therapy in Crohn's disease of any severity 1
• Systemic corticosteroids should be limited to no longer than 8 weeks due to adverse effects 1
• Early assessment of response (within 2 weeks) is recommended to allow timely escalation to more effective treatment if needed 1

5-ASA Medications

• Oral 5-ASA medications (other than sulfasalazine) are NOT recommended for induction or maintenance of remission in Crohn's disease 1
• High-dose mesalamine (4 g/day) has not shown significant benefit over placebo 2

Maintenance Therapy After Induction

• For patients who achieve remission on corticosteroids, thiopurine therapy (azathioprine/6-mercaptopurine) is suggested for maintenance 1
• Parenteral methotrexate may be used for maintenance in patients who achieved remission with corticosteroids and methotrexate 1
• Thiopurines are not recommended for induction of remission 1

Advanced Therapy for Moderate to Severe Disease

• For patients with moderate to severe disease with risk factors for poor prognosis, anti-TNF therapy (infliximab, adalimumab) is recommended as first-line therapy 1
• Combination therapy of anti-TNF with immunomodulator (thiopurine or methotrexate) is more effective than monotherapy 1
• The AGA suggests early introduction of biologics with or without immunomodulators rather than delaying their use until after failure of mesalamine and/or corticosteroids 1

Antibiotics

• Systemically absorbed antibiotics are not recommended for induction or maintenance of remission in luminal Crohn's disease 1

Treatment Algorithm

1. Assess disease severity and location
2. For mild-moderate ileal/right colonic disease: Start budesonide 9 mg/day
3. For mild colonic disease: Start sulfasalazine 4-6 g/day
4. For moderate-severe disease: Start prednisone 40-60 mg/day or consider early anti-TNF therapy if poor prognostic factors present
5. Evaluate response within appropriate timeframe (2-8 weeks depending on therapy)
6. If response achieved, transition to appropriate maintenance therapy
7. If inadequate response, escalate to next appropriate therapy

Common Pitfalls to Avoid

• Using 5-ASA medications (except sulfasalazine for colonic disease) as they lack efficacy 1, 2
• Continuing corticosteroids for maintenance therapy 1
• Delaying evaluation of treatment response, which may lead to disease progression 1
• Using thiopurines alone for induction of remission 1
• Multiple courses of corticosteroids without implementing effective maintenance strategies 1