What are the treatment options for Crohn's Disease?

Treatment Options for Crohn's Disease

For mild-to-moderate Crohn's disease limited to the ileum and/or ascending colon, budesonide 9 mg daily for 8 weeks is the recommended first-line therapy; for moderate-to-severe disease, systemic corticosteroids (prednisone 40-60 mg daily or IV methylprednisolone 40-60 mg daily) are strongly recommended, followed by maintenance therapy with thiopurines, methotrexate, or anti-TNF biologics to prevent relapse. 1, 2, 3

Induction Therapy by Disease Severity

Mild-to-Moderate Disease (Ileal/Right Colonic)

• Budesonide 9 mg daily is superior to placebo for inducing clinical response (RR: 1.46) and remission (RR: 1.93) at 8 weeks, with better safety profile than systemic steroids due to high topical activity and low systemic absorption 1, 2, 3
• Budesonide should be used specifically for disease limited to the ileum and/or ascending colon 1

Mild-to-Moderate Colonic Disease

• Sulfasalazine may be considered for colonic Crohn's disease, showing borderline efficacy (RR: 1.38) limited to patients with colonic involvement 1, 4
• 5-ASA compounds (mesalazine) are NOT recommended for induction or maintenance of remission in Crohn's disease, as they show no significant effect on clinical remission (RR: 1.28) 1, 3

Moderate-to-Severe Disease

• Oral prednisone 40-60 mg daily is strongly recommended as first-line therapy, being twice as effective as placebo for inducing remission 2, 3
• For hospitalized patients requiring IV therapy, methylprednisolone 40-60 mg daily (typically 40 mg every 8 hours) provides more predictable drug delivery 2
• Evaluate response to steroids between 2-4 weeks for oral therapy and within 1 week for IV therapy to determine need for therapy modification 2
• Taper prednisone gradually over 8 weeks, as more rapid reduction increases risk of early relapse 2

Maintenance Therapy

Immunomodulators

• Azathioprine or mercaptopurine is recommended for patients who are steroid-dependent, have adverse prognostic factors, or need maintenance after steroid-induced remission 2, 3
• Methotrexate should be considered for maintenance only in patients who needed methotrexate to induce remission, cannot tolerate thiopurines, or have contraindications to azathioprine/mercaptopurine 2, 3
• Early introduction of maintenance therapy with thiopurines or methotrexate while tapering corticosteroids prevents repeated steroid exposure 3

Biologic Therapy

• Anti-TNF therapy (infliximab, adalimumab) is strongly recommended as first-line or after failure of conventional therapy for moderate-to-severe disease with poor prognostic risk factors 2, 5
• Combination therapy with infliximab plus thiopurine is more effective than monotherapy for maintaining remission 3
• Assess response to anti-TNF therapy between 8-12 weeks; consider discontinuation and alternative treatment if no response by week 14 3
• Vedolizumab is recommended for patients who fail corticosteroids, thiopurines, methotrexate, or anti-TNF therapy, with response evaluation between 10-14 weeks 2
• Ustekinumab is recommended for moderate-to-severe disease after failure of other therapies, with response evaluation between 6-10 weeks 2, 6
• Patients who respond to biologic therapy should continue the same agent for maintenance 2

Critical Monitoring and Safety Considerations

Disease Monitoring

• Regular monitoring with objective markers (endoscopy, CRP, calprotectin, imaging) is crucial due to disconnect between clinical symptoms and underlying inflammation 1, 2
• Rule out complications such as abscess, stricture, or infection before initiating treatment 3

Steroid-Related Precautions

• Corticosteroids should NOT be used for maintenance therapy in Crohn's disease of any severity 2, 3
• Monitor for steroid-related adverse effects including increased risk of abdominal/pelvic abscesses, Cushing syndrome, hypertension, diabetes, and osteoporosis 3

Thiopurine Safety

• Monitor for neutropenia with thiopurines regardless of TPMT status 3
• Establish documented local safety monitoring policies with regular blood counts even with normal TPMT activity 3

Therapies NOT Recommended

• Antibiotics have no demonstrated efficacy for luminal Crohn's disease, though they remain indicated for septic complications 1
• Probiotics, omega-3 fatty acids, marijuana, and naltrexone are not recommended for inducing or maintaining remission 2
• Enteral nutrition or dietary modification alone are not suggested for inducing or maintaining remission in adults 2
• Long-term opioid use should be avoided as it is associated with poor outcomes in IBD patients 2

Special Considerations

• Up to 50% of patients require surgery within 10 years of diagnosis, and up to one-third present with complicated behavior (strictures, fistula, abscesses) at diagnosis 2
• Joint medical and surgical management is appropriate for severe disease 2
• For patients with pain symptoms alongside depression, tricyclic antidepressants may offer dual benefits 2