What are the treatment options for someone experiencing symptoms of Crohn's disease?

Treatment Options for Crohn's Disease

For patients with Crohn's disease, treatment should be stratified based on disease severity, location, and pattern, with biologic therapies recommended as first-line for moderate to severe disease to achieve complete remission and prevent complications. 1

Disease Assessment and Classification

• Crohn's disease should be categorized as mild, moderate, or severe, considering clinical symptoms, inflammatory markers, and extent of disease involvement 1
• Disease location (ileal, colonic, ileocolonic) and pattern (inflammatory, stricturing, penetrating) must be determined before selecting appropriate treatment 1
• Up to one-third of patients present with complicated behavior (strictures, fistula, abscesses) at diagnosis, with most developing complications over time 2

Treatment Options by Disease Severity

Mild to Moderate Disease

• For mild to moderate ileal and/or right colonic disease, oral budesonide 9 mg/day is recommended as first-line therapy 1
• Conventional glucocorticosteroids (prednisolone, methylprednisolone, or IV hydrocortisone) are recommended for first presentation or single inflammatory exacerbation in a 12-month period 2
• Response to prednisone should be evaluated between 2-4 weeks to determine need for therapy modification 1
• Prednisone should be tapered gradually over 8 weeks to reduce risk of early relapse 1

Moderate to Severe Disease

• Oral prednisone 40-60 mg/day is strongly recommended for moderate to severe disease 1
• Anti-TNF therapy (infliximab, adalimumab) is strongly recommended for:
  • Patients with risk factors for poor prognosis 1
  • Those who fail conventional therapy 3, 4
  • Patients with fistulizing disease 3
• Vedolizumab is recommended for patients who fail to achieve complete remission with corticosteroids, thiopurines, methotrexate, or anti-TNF therapy 2
• Ustekinumab is recommended for patients with moderate to severe disease who fail other therapies 2

Maintenance Therapy

• Corticosteroids should NOT be used for maintenance therapy 1
• Azathioprine or mercaptopurine is recommended:
  • When previously used with corticosteroids to induce remission 2
  • For patients with adverse prognostic factors (early age of onset, perianal disease) 2
  • To maintain remission after surgery in high-risk patients 2
• Methotrexate should be considered for maintenance only in patients who:
  • Needed methotrexate to induce remission 2
  • Have tried but did not tolerate azathioprine or mercaptopurine 2
  • Have contraindications to azathioprine or mercaptopurine 2
• Patients who respond to biologic therapy should continue the same agent for maintenance 2

Monitoring and Follow-up

• Regular monitoring with objective markers (endoscopy, CRP, calprotectin, imaging) is crucial due to disconnect between symptoms and inflammation 2
• For vedolizumab, evaluate response between 10-14 weeks 2
• For ustekinumab, evaluate response between 6-10 weeks 2
• Patients who choose not to receive maintenance treatment should know which symptoms may suggest relapse (unintended weight loss, abdominal pain, diarrhea, general ill-health) 2

Treatments Not Recommended

• Probiotics, omega-3 fatty acids, marijuana, and naltrexone are not recommended for inducing or maintaining remission 2, 1
• Enteral nutrition or dietary modification alone are not suggested for inducing or maintaining remission in adults 2, 1
• Long-term opioid use should be avoided as it's associated with poor outcomes 1

Special Considerations

• Joint medical and surgical management is appropriate for severe disease 1
• Up to 50% of patients require surgery within 10 years of diagnosis 2
• Patients on immunosuppressive therapy should not receive live vaccines 1
• Patients should be monitored for potential adverse effects of medications, including infections and malignancies with biologic therapies 3