What is the initial treatment for a Crohn's proctitis flare?

Treatment of Crohn's Proctitis Flare

For patients with Crohn's proctitis flare, the initial treatment should be topical mesalazine (5-ASA) suppositories at a dosage of 1 g daily, which is effective for mild to moderate disease limited to the rectum. 1

First-Line Treatment Options

• Topical mesalazine (5-ASA) suppositories at 1 g daily are recommended as first-line therapy for mild to moderate ulcerative proctitis and can be effective in left-sided colonic Crohn's disease of mild to moderate activity 1
• For patients with incomplete response to topical therapy alone, addition of oral 5-ASA at 2-3 g daily is recommended to improve response rates 1
• If symptoms persist despite optimized 5-ASA therapy, corticosteroid suppositories (e.g., 5 mg prednisolone) can be added while continuing oral 5-ASA therapy 1

Treatment Algorithm Based on Response

Mild to Moderate Proctitis:

1. Start with 1 g 5-ASA suppository once daily (usually at night) 1
2. If incomplete response, add oral 5-ASA 2-3 g daily 1
3. If still incomplete response, add or switch to corticosteroid suppository (e.g., 5 mg prednisolone) and optimize oral 5-ASA to 4-4.8 g daily 1

Refractory Disease:

• For patients who fail to respond to topical and oral 5-ASA therapy, systemic corticosteroids (oral prednisolone 40 mg daily with gradual taper over 6-8 weeks) should be initiated 1
• For perianal disease or fistulae, metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily are appropriate first-line treatments 1

Important Considerations

• Always rule out other causes of symptoms such as infection, proximal constipation, or rectal prolapse before determining treatment failure 1
• The efficacy of 5-ASA in Crohn's disease is controversial and appears to be modest compared to ulcerative colitis, with benefit mainly confined to patients with colonic involvement 2, 3
• For patients with more extensive disease beyond proctitis, systemic therapy may be required earlier 1, 4

Maintenance Therapy After Flare Resolution

• After achieving remission, maintenance therapy with 1 g 5-ASA suppository daily is recommended 1
• For improved adherence, frequency can be reduced to every 2nd or 3rd day, or switched to oral 5-ASA 1
• For patients with frequent relapses or steroid-dependent disease, immunomodulators such as azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) should be considered 1, 4

Treatment Pitfalls to Avoid

• Do not rely solely on 5-ASA therapy for moderate to severe Crohn's disease as its efficacy is limited compared to ulcerative colitis 2, 3
• Avoid prolonged corticosteroid use due to risk of side effects; they should not be used for maintenance therapy 4
• Poor adherence to 5-ASA therapy is associated with increased risk of flares; higher doses may be beneficial in patients with low adherence 5
• Always assess for complications such as abscesses or fistulae that may require specific interventions before initiating treatment 4

By following this structured approach to treating Crohn's proctitis flares, clinicians can effectively manage symptoms while minimizing disease progression and complications.