What is the treatment for a Crohn's disease (Crohn's disease) flare?

From the Guidelines

Treatment for a Crohn's disease flare should prioritize minimizing corticosteroid use due to toxicity and lack of efficacy as maintenance therapy, as recommended by the British Society of Gastroenterology consensus guidelines 1.

Key Considerations

• For mild to moderate flares, oral corticosteroids like prednisone or budesonide may be used initially, but every effort should be made to limit exposure due to their toxicity and lack of efficacy as maintenance therapy 1.
• For more severe flares, stronger immunosuppressants such as azathioprine or mercaptopurine can be used as monotherapy for maintaining remission 1, and biologic agents like infliximab or adalimumab may be required for severe or refractory cases 1.
• Exclusive enteral nutrition (EEN) or a Crohn’s disease exclusion diet may be effective for induction of clinical remission and endoscopic response in mild to moderate Crohn’s disease, especially in pediatric patients or as a steroid-sparing therapy 1.

Management Strategies

• During flares, patients should maintain adequate hydration, consider a low-residue diet to reduce bowel irritation, rest as needed, and avoid NSAIDs which can worsen symptoms.
• Methotrexate may be used for the maintenance of remission of Crohn’s disease, with a recommended dose of at least 15 mg weekly, and subcutaneous administration is preferred for better bioavailability 1.
• The choice of treatment should be individualized based on the severity of the flare, disease location, patient preferences, and potential side effects of the medications.

Prioritizing Outcomes

• The primary goal of treatment is to reduce inflammation, manage symptoms, and improve quality of life while minimizing the risk of morbidity and mortality associated with Crohn's disease and its treatment.
• Regular monitoring and follow-up are crucial to adjust the treatment plan as needed and to prevent complications.

From the FDA Drug Label

RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adults with moderately to severely active Crohn's disease or fistulizing Crohn's disease

Treatment for Crohn's Flare:

• The recommended dose for treating a Crohn's flare is not explicitly stated in the label, but the standard induction regimen is 5 mg/kg at 0,2, and 6 weeks.
• For adult patients who respond and then lose their response, consideration may be given to treatment with 10 mg/kg.
• Patients who do not respond by Week 14 are unlikely to respond with continued dosing and consideration should be given to discontinue RENFLEXIS in these patients 2.

From the Research

Treatment Options for Crohn's Flare

• The treatment of Crohn's disease depends on disease severity, patient risk stratification, patient preference, and clinical factors, including age of onset and penetrating complications 3.
• First-line therapy generally consists of steroids for rapid palliation of symptoms during initiation of anti-tumor necrosis factor α therapy 3.
• Other treatments may include monoclonal antibodies to IL-12/23 or integrin α4β7, immunomodulators, combination therapies, or surgery 3.
• For ambulatory outpatients with low-risk, mild, ileal or ileocolonic CD, induction of remission with budesonide is recommended 4.
• For colonic CD, sulfasalazine is a reasonable choice, although other aminosalicylates have no role in the treatment of CD 4.

Biologic Therapies

• Biologics targeting tumor necrosis factor (TNF)-α, α4ß7 integrins, interleukin (IL)-12/23 or IL-23, as well as Janus kinase (JAK) inhibitors, sphingosine 1‑phosphate receptor (S1PR) modulators, and calcineurin inhibitors are available for the treatment of severe flares in Crohn's disease 5.
• Infliximab, a biologic therapy, has been shown to be effective in inducing and maintaining remission in patients with moderate-to-severe Crohn's disease 6.
• Combination therapy with infliximab and azathioprine has been shown to be more effective than infliximab or azathioprine monotherapy in achieving corticosteroid-free clinical remission and mucosal healing 6.

Management of Severe Flares

• Intravenous steroid therapy is indicated in severe acute flares for both CD and UC, which should lead to improvement within the first 72 h 5.
• If no improvement occurs, medical therapy must be intensified, and various therapeutics, including biologics, are available 5.
• Surgical options must always be considered as part of close interdisciplinary care 5.