What are the treatment options for a Crohn's disease flare?

Treatment Options for Crohn's Disease Flare

For patients experiencing a Crohn's disease flare, corticosteroids are recommended for induction of remission, followed by early introduction of biologics with or without immunomodulators for maintenance therapy. 1

First-Line Treatment for Acute Flare

Corticosteroids

• Corticosteroids are effective for inducing remission in moderate to severe Crohn's disease flares 1
• For mild to moderate disease limited to the ileum and/or ascending colon, budesonide 9 mg/day is recommended due to its better safety profile 1
• For more extensive or severe disease, systemic corticosteroids (prednisolone 40-60 mg/day) are recommended 1, 2
• Important caveat: Corticosteroids should NOT be used for maintenance therapy due to significant side effects including bone loss, metabolic complications, and increased infection risk 1, 3

Disease Location Considerations

• For disease limited to the ileum and/or right colon: budesonide 9 mg/day is preferred 1
• For more extensive disease or higher disease activity: systemic corticosteroids 1, 2
• For isolated proctitis: topical therapy with corticosteroid suppositories may be considered 1, 4

Maintenance Therapy After Flare Control

Biologics

• Early introduction of biologics (TNF inhibitors) with or without immunomodulators is recommended after achieving remission with corticosteroids 1, 5
• TNF inhibitors approved for Crohn's disease include:
  • Infliximab: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 6
  • Adalimumab: 160 mg SC initially, 80 mg at week 2, then 40 mg every 2 weeks 7
• Combination therapy with infliximab and a thiopurine is more effective than monotherapy for maintaining remission 1

Immunomodulators

• Thiopurines (azathioprine, mercaptopurine) or methotrexate should be considered for maintenance therapy after corticosteroid-induced remission 1
• Methotrexate should be administered subcutaneously at a dose of at least 15 mg weekly with folic acid supplementation 1
• Thiopurines alone are not recommended for induction of remission but are effective for maintenance 1, 2

Treatment Strategy Based on Disease Severity

Mild to Moderate Disease

• Budesonide 9 mg/day for disease limited to ileum/right colon 1
• If inadequate response, progress to systemic corticosteroids 1, 2

Moderate to Severe Disease

• Systemic corticosteroids for induction of remission 1, 2
• Early introduction of biologics (TNF inhibitors) with or without immunomodulators 1, 5
• For patients with high-risk features (complex disease, perianal fistulizing disease, age <40 at diagnosis), consider earlier introduction of combination therapy 5, 2

Important Considerations

Ineffective Treatments

• Mesalazine (5-ASA) is NOT recommended for induction or maintenance of remission in Crohn's disease 1
• Antibiotics have not consistently demonstrated efficacy for luminal Crohn's disease, though they remain indicated for septic complications 1

Monitoring Response

• Evaluate response to corticosteroids within 2-4 weeks 2
• Assess response to anti-TNF therapy between 8-12 weeks 2
• If no response by week 14 of anti-TNF therapy, consider discontinuation and alternative treatment 6

Safety Considerations

• Screen for tuberculosis and other infections before starting biologics 6, 7
• Combination therapy with anti-TNF agents and immunomodulators may increase risk for lymphoma and serious infections 5, 6
• Consider thiopurine methyltransferase activity assessment before starting azathioprine or mercaptopurine 5

Treatment Algorithm

1. For acute flare: Start with corticosteroids (budesonide for limited disease, systemic steroids for extensive disease) 1
2. Plan early introduction of maintenance therapy as steroids are tapered 1
3. For maintenance: TNF inhibitors (preferably in combination with thiopurine for infliximab) or immunomodulators 1
4. For patients not responding to first-line therapy: Consider alternative biologics (ustekinumab, vedolizumab) 5, 2