What is the typical hospital treatment for a Crohn's disease flare?

Hospital Treatment for Crohn's Disease Flare

For patients with Crohn's disease requiring hospitalization due to severe disease activity, intravenous corticosteroids (methylprednisolone 40-60 mg/day) should be initiated immediately to induce symptomatic remission. 1

Initial Assessment Upon Admission

• Rule out complications that require specific interventions rather than medical therapy alone, including intra-abdominal abscess, intestinal stricture with obstruction, or superimposed infection (such as Clostridium difficile). 2
• Confirm active inflammation using biomarkers such as C-reactive protein (CRP) and fecal calprotectin to distinguish true inflammatory flares from functional symptoms. 2
• Assess disease location and extent as this influences both immediate and subsequent treatment decisions. 1

Induction Therapy in Hospital

Intravenous Corticosteroids (First-Line)

• Administer methylprednisolone 40-60 mg/day intravenously as the standard approach for severe Crohn's disease requiring hospitalization. 1
• Evaluate clinical response within 1 week to determine whether therapy modification is needed—patients who fail to respond require escalation to biologic therapy. 1
• The evidence supporting IV corticosteroids is conditional with low-quality data, but this remains standard practice for hospitalized patients. 1

Early Biologic Consideration

• For patients with moderate-to-severe disease and risk factors for poor prognosis (young age at diagnosis, extensive disease, perianal involvement, deep ulcerations, prior surgery), consider initiating anti-TNF therapy during hospitalization rather than waiting for corticosteroid response. 1
• Infliximab is preferred in the hospital setting due to its intravenous administration and rapid onset of action, dosed at 5 mg/kg at weeks 0,2, and 6. 1, 3
• Combination therapy with infliximab plus a thiopurine (azathioprine or 6-mercaptopurine) is more effective than monotherapy for inducing and maintaining remission. 1

Monitoring Response and Treatment Modification

Corticosteroid Response Assessment

• If no symptomatic improvement within 1 week of IV corticosteroids, escalate to biologic therapy immediately rather than continuing ineffective steroid treatment. 1
• Once clinical improvement occurs, transition from IV to oral corticosteroids (prednisone 40-60 mg/day) and plan for discharge with outpatient taper. 1

Planning Maintenance Therapy

• Initiate maintenance therapy before discharge to prevent relapse after corticosteroid taper—corticosteroids must never be used for maintenance. 1, 2
• Options for maintenance include:
  • Anti-TNF biologics (infliximab or adalimumab) with or without thiopurine combination therapy 1
  • Ustekinumab for patients with inadequate response to or contraindications to anti-TNF therapy 1
  • Thiopurines (azathioprine 2-2.5 mg/kg/day or 6-mercaptopurine 1-1.5 mg/kg/day) for selected patients who achieved remission on corticosteroids 1
  • Parenteral methotrexate (15-25 mg subcutaneously weekly) as an alternative immunosuppressant 1

Important Contraindications and Cautions

What NOT to Use

• Do NOT use 5-ASA/mesalazine for induction or maintenance of remission in Crohn's disease—it is ineffective regardless of disease severity or location. 1, 4, 2
• Do NOT use oral budesonide for hospitalized patients with severe disease—it is only appropriate for mild-to-moderate ileal/right colonic disease in outpatients. 1, 4
• Do NOT continue corticosteroids for maintenance—they carry significant risks including infections, metabolic complications, osteoporosis, and increased intra-abdominal abscess formation without preventing relapse. 1, 2

Corticosteroid-Related Complications

• Monitor for steroid-related adverse effects including increased risk of abdominal/pelvic abscesses (particularly concerning in Crohn's disease), Cushing syndrome, hyperglycemia, hypertension, and osteoporosis. 2
• Screen for latent tuberculosis before initiating biologic therapy, as the combination of corticosteroids and biologics significantly increases infection risk. 3

Treatment Algorithm for Hospitalized Patients

1. Day 1-7: IV methylprednisolone 40-60 mg/day + rule out complications + assess for poor prognostic factors 1, 2

2. If high-risk features present: Add infliximab 5 mg/kg IV (with thiopurine if not contraindicated) during hospitalization 1

3. If standard risk and responding to steroids by day 7: Transition to oral prednisone, discharge with outpatient follow-up, and initiate maintenance therapy (thiopurine or biologic) 1, 4

4. If no response by day 7: Escalate to anti-TNF therapy (infliximab preferred) or ustekinumab if anti-TNF contraindicated 1

5. Before discharge: Ensure maintenance therapy initiated, corticosteroid taper plan established, and follow-up scheduled within 2-4 weeks 1, 4

Post-Discharge Monitoring

• Evaluate response to anti-TNF induction between 8-12 weeks after initiation—if no response by week 14, discontinue and switch to alternative biologic. 4, 5
• Taper prednisone over 8-12 weeks while monitoring for symptom recurrence that would indicate need for maintenance therapy optimization. 4
• Assess for steroid dependency—patients requiring repeated courses or unable to taper below 10 mg/day require escalation to biologic or immunomodulator therapy. 2