What is the treatment for an acute Crohn's (inflammatory bowel disease) attack?

Treatment of Acute Crohn's Disease Attack

For an acute Crohn's disease flare, initiate oral corticosteroids (prednisolone 40 mg daily or prednisone 0.5-1 mg/kg/day) as first-line therapy for moderate to severe disease, tapering gradually over 8-17 weeks based on clinical response. 1

Disease Severity Assessment and Initial Treatment Strategy

The treatment approach must be stratified by disease severity and location:

Mild to Moderate Disease

• For mild ileocolonic Crohn's disease, consider high-dose oral mesalazine (4 g daily) as initial therapy, though evidence for efficacy is modest at best 1, 2
• Budesonide (9 mg daily) is an appropriate alternative for active ileo-ascending colonic disease with reduced systemic toxicity compared to prednisolone, though slightly less effective 1

Moderate to Severe Disease

• Oral prednisolone 40 mg daily is the optimal dose for outpatient management; higher doses (60 mg) increase adverse events without added benefit 1
• Prednisone 0.5-0.75 mg/kg/day (higher dose for more severe disease) achieves 60% remission compared to 30% with placebo (NNT=3) 1
• Prednisone 1 mg/kg/day achieves 83% remission compared to 38% with placebo (NNT=2) over 18 weeks 1
• Taper gradually over 8 weeks minimum; rapid reduction associates with early relapse 1

Severe or Refractory Disease Requiring Hospitalization

Admit patients for intensive intravenous therapy if they fail maximal oral treatment or present with severe disease 1:

Inpatient Management Protocol

• Intravenous corticosteroids (hydrocortisone or methylprednisolone) as initial medical treatment 1
• Intravenous fluid and electrolyte replacement to correct dehydration 1
• Subcutaneous heparin for thromboprophylaxis 1
• Nutritional support (enteral or parenteral) if malnourished 1
• Daily monitoring: vital signs four times daily, stool frequency/character, complete blood count, inflammatory markers (CRP), electrolytes, albumin, liver function tests 1
• Joint medical-surgical management with a colorectal surgeon experienced in IBD 1

Rescue Therapy for Steroid-Refractory Disease

If no response by day 3 of intravenous steroids in hemodynamically stable patients, initiate rescue therapy 1:

• Infliximab 5 mg/kg at weeks 0,2, and 6 is the preferred rescue agent 1, 3
• Combination with azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) improves efficacy over monotherapy 1
• Adalimumab is an alternative: 160 mg on Day 1 (single dose or split over two consecutive days), 80 mg on Day 15, then 40 mg every other week starting Day 29 4

Special Clinical Scenarios

Fistulating and Perianal Disease

• Metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily as first-line for simple perianal fistulae 1
• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day for simple perianal or enterocutaneous fistulae after excluding distal obstruction and abscess 1
• Infliximab (5 mg/kg at weeks 0,2, and 6) reserved for refractory fistulae as part of combined medical-surgical strategy 1
• Surgical drainage (Seton placement, fistulectomy, advancement flaps) in combination with medical treatment for persistent or complex fistulae 1

Intra-abdominal Abscesses

• Percutaneous drainage plus antibiotics as first-line for abscesses >3 cm in stable patients 1
• Antibiotics alone may be attempted for abscesses <3 cm, though recurrence risk is high, especially with enteric fistula 1
• Surgery indicated for failed percutaneous drainage or septic shock 1

Critical Pitfalls to Avoid

Do not delay corticosteroid initiation while awaiting stool microbiology results, even when infectious colitis cannot be excluded 1

Avoid doses of prednisolone <15 mg daily for active disease—they are ineffective 1

Do not use corticosteroids for maintenance therapy—they have no role in maintaining remission and should be completely withdrawn 1

Recognize steroid-dependent disease early: patients requiring two or more courses within a calendar year, those unable to taper below 15 mg, or those relapsing within 6 weeks of stopping steroids should be transitioned to steroid-sparing agents (azathioprine, mercaptopurine, or biologics) 1

Patients who do not respond by Week 14 are unlikely to respond with continued dosing; consider treatment escalation or surgical consultation 3

Preoperative Considerations

Preoperative immunomodulators (azathioprine/mercaptopurine) combined with anti-TNF agents and steroids increase risk of intra-abdominal sepsis in patients requiring emergency resectional surgery 1

Surgery should be considered for medically refractory disease, perforation, persistent obstruction, abscess not amenable to drainage, intractable hemorrhage, or dysplasia/cancer 5