What is the initial treatment for a patient with Crohn's disease presenting with a flare in the hospital?

Initial Hospital Treatment for Crohn's Disease Flare

For patients with Crohn's disease presenting with a flare requiring hospitalization, initiate intravenous methylprednisolone 40-60 mg/day immediately after ruling out complications such as intra-abdominal abscess, intestinal obstruction, or superimposed infection. 1

Immediate Assessment and Supportive Care

Before starting corticosteroids, you must exclude complications that require specific interventions rather than medical therapy alone:

• Rule out intra-abdominal abscess using CT imaging—abscesses >3 cm require percutaneous drainage plus antibiotics, not steroids alone 2
• Rule out intestinal obstruction from strictures that may require surgical intervention 2
• Rule out Clostridium difficile infection and other superimposed infections before immunosuppression 1
• Confirm active inflammation using C-reactive protein (CRP) and fecal calprotectin to distinguish true inflammatory flares from functional symptoms 1

All hospitalized patients require:

• Adequate intravenous fluid resuscitation to correct volume depletion 2
• Low-molecular-weight heparin for thromboprophylaxis given the hypercoagulable state in active IBD 2
• Correction of electrolyte abnormalities and anemia 2

Induction Therapy: Intravenous Corticosteroids

Administer methylprednisolone 40-60 mg/day intravenously (typically given as 40 mg every 8 hours) as the standard approach for severe Crohn's disease requiring hospitalization 1. This achieves remission in 60-83% of hospitalized patients 3. The high response rate (mean 88%) serves to buy time for establishment of successful maintenance programs 4.

Evaluate clinical response by day 3 and definitively by day 7 after starting intravenous corticosteroids 2, 1. Patients who fail to respond by 1 week require escalation to biologic therapy 1.

When to Avoid Corticosteroids

Do not use corticosteroids or use with extreme caution in:

• Poorly controlled diabetes 3
• History of steroid-induced psychosis or depression 3
• Active infection or sepsis—antibiotics should only be given if superinfection or abscess is present, not routinely 2

Early Biologic Therapy for High-Risk Patients

For patients with moderate-to-severe disease and poor prognostic factors, consider initiating anti-TNF therapy during hospitalization rather than waiting for corticosteroid response 1. High-risk features include:

• Young age at diagnosis (<40 years) 2
• Extensive disease 1
• Perianal involvement 1
• Deep ulcerations 1
• Prior surgery 2
• Complex (stricturing or penetrating) disease at presentation 2

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, 5. Combination therapy with infliximab plus a thiopurine (azathioprine or 6-mercaptopurine) is more effective than monotherapy for inducing and maintaining remission 1.

Rescue Therapy for Steroid-Refractory Disease

If patients fail to respond to intravenous corticosteroids by day 7, initiate infliximab as rescue therapy 1, 6. In hospitalized Crohn's disease patients failing IV corticosteroids, infliximab achieves response in 88% with low rates of urgent surgery 6. The median hospital stay following rescue infliximab is 3 days 6.

Maintenance Therapy Planning Before Discharge

Corticosteroids must never be used for maintenance therapy—this is a strong recommendation against their use for maintaining remission in Crohn's disease of any severity 3, 1. Initiate maintenance therapy before discharge to prevent relapse after corticosteroid taper 1.

Maintenance options 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

Taper prednisone over 8-12 weeks while monitoring for symptom recurrence that would indicate need for maintenance therapy optimization 1. Rapid tapering (10 mg/week) should be considered where possible to limit steroid exposure 2.

Critical Monitoring and Follow-Up

• Assess for steroid dependency—patients requiring repeated courses or unable to taper below 10 mg/day require escalation to biologic or immunomodulator therapy 1
• Evaluate response to anti-TNF induction between 8-12 weeks after initiation—if no response by week 14, discontinue and switch to alternative biologic 1
• Provide calcium and vitamin D supplementation to all patients on corticosteroids to prevent bone loss 3
• Readmission rates after rescue infliximab are 29% at 30 days and 47% at 90 days, requiring close outpatient follow-up 6

Common Pitfalls to Avoid

Do not delay imaging to rule out complications—starting steroids in the presence of an abscess can lead to sepsis and death 2. Do not use antibiotics routinely—they should only be given if superinfection or abscess is documented 2. Do not discharge patients on corticosteroids without a maintenance plan—35% of initial responders develop steroid-dependency and up to 13% require colectomy without proper maintenance therapy 7. Do not continue corticosteroids beyond 8-12 weeks—prolonged exposure increases infection risk and does not maintain remission 2, 3.