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

Treatment of Acute Crohn's Disease Attack

First-Line Therapy for Moderate to Severe Disease

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

Corticosteroid Dosing and Efficacy

• Prednisolone 40 mg daily is the optimal outpatient dose—higher doses (60 mg) increase adverse events without added benefit 1
• Prednisone 0.5-0.75 mg/kg/day achieves 60% remission versus 30% with placebo (NNT=3), while 1 mg/kg/day achieves 83% remission versus 38% with placebo (NNT=2) over 18 weeks 1
• Do not delay corticosteroid initiation while awaiting stool microbiology results, even when infectious colitis cannot be excluded 1

Alternative for Ileocolonic Disease

• Budesonide 9 mg daily is appropriate for active ileo-ascending colonic disease with reduced systemic toxicity compared to prednisolone, though slightly less effective 1

Mesalazine Has Limited Role

• High-dose oral mesalazine (4 g daily) may be considered for mild ileocolonic Crohn's disease, though evidence for efficacy is modest at best 1
• Multiple systematic reviews confirm that mesalazine (3-4.5 g/day) is not superior to placebo for inducing remission or response in active Crohn's disease 2
• Sulfasalazine shows only modest efficacy (RR 1.38 for remission vs placebo), with benefit confined mainly to patients with colitis 2

Severe 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
• IV 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

Perianal Fistulizing Disease

Simple Perianal Fistulae

• Metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily as first-line therapy 1
• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day after excluding distal obstruction and abscess 1

Refractory Fistulae

• 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

Abscess Management

• 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

Ineffective Dosing

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

Steroid Maintenance Error

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Do not use corticosteroids for maintenance therapy—they have no role in maintaining remission and should be completely withdrawn 1

Recognizing Steroid Dependence

• Identify 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 1
• These patients should be transitioned to steroid-sparing agents (azathioprine, mercaptopurine, or biologics including anti-TNF agents) 1, 3

Preoperative Risk

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