What is the recommended treatment plan for a patient with Crohn's disease?

Treatment Plan for Crohn's Disease

For patients with moderate to severe Crohn's disease, anti-TNF therapy (infliximab or adalimumab) is the recommended first-line treatment to induce and maintain complete remission, particularly in those with poor prognostic factors such as young age, perianal disease, stricturing/penetrating disease, or need for steroids at diagnosis. 1

Disease Severity Assessment and Risk Stratification

Before initiating treatment, disease severity must be categorized as mild, moderate, or severe based on clinical symptoms, inflammatory markers (CRP, fecal calprotectin), and extent of disease involvement. 2

Poor prognostic factors that warrant aggressive first-line biologic therapy include: 1, 2

• Age under 40 years at diagnosis
• Perianal fistulizing disease
• Stricturing or penetrating disease behavior
• Extensive small bowel involvement
• Deep ulcerations on endoscopy
• Need for corticosteroids at presentation

Treatment Algorithm by Disease Severity

Mild Disease (Ambulatory, No High-Risk Features)

For mild ileal or ileocolonic disease: 3

• Oral budesonide 9 mg/day is first-line therapy for induction 1
• Evaluate response at 2-4 weeks 2

For mild colonic disease: 3

• Sulfasalazine is a reasonable option 1
• Other aminosalicylates have no proven role in Crohn's disease 3

Moderate to Severe Disease

First-line therapy depends on risk stratification: 1

High-risk patients (with poor prognostic factors):

• Start anti-TNF therapy immediately (infliximab 5 mg/kg IV at weeks 0,2,6, then every 8 weeks OR adalimumab) 1, 4
• Consider combination therapy with thiopurine (azathioprine or mercaptopurine) to improve pharmacokinetics and reduce antibody formation 1
• Evaluate response at 8-12 weeks 1

Standard-risk patients:

• Prednisone 40-60 mg/day orally for rapid symptom control 1, 2
• Taper gradually over 8 weeks once response achieved 1
• Evaluate response at 2-4 weeks 2
• If inadequate response, steroid-dependent, or steroid-resistant: escalate to anti-TNF therapy 1

Severe Disease Requiring Hospitalization

• IV methylprednisolone 40-60 mg/day (typically 40 mg every 8 hours) 2
• Evaluate response within 1 week 1
• If no response: transition to anti-TNF therapy or consider surgery 2
• Joint medical-surgical management is appropriate 2

Maintenance Therapy

After achieving remission with anti-TNF induction: 1

• Continue the same anti-TNF agent indefinitely (infliximab 5 mg/kg every 8 weeks or adalimumab equivalent dosing) 1, 4
• Do NOT discontinue therapy based solely on achieving remission—discontinuation carries approximately 33% relapse risk within 1-2 years 5
• Do NOT switch between anti-TNF agents in patients doing well on current therapy 1

For patients who achieved remission with corticosteroids: 1

• Offer azathioprine or mercaptopurine for maintenance (corticosteroids must NOT be used for maintenance) 1
• Consider thiopurines particularly in patients with adverse prognostic factors 1

For patients intolerant of thiopurines: 1

• Parenteral methotrexate (25 mg SC/IM weekly) for maintenance 1

Management of Suboptimal Response or Loss of Response

If suboptimal response to anti-TNF induction (by 8-12 weeks): 1

• Dose intensification (increase to 10 mg/kg for infliximab) 1, 4
• Therapeutic drug monitoring to guide optimization 1

If loss of response during maintenance: 1

• Therapeutic drug monitoring to assess drug levels and antibodies 1
• Dose optimization based on levels 1
• If continued failure: switch to alternative biologic class 1

Second-Line Biologic Options

For patients who fail anti-TNF therapy, corticosteroids, thiopurines, or methotrexate: 1

• Vedolizumab (gut-selective anti-integrin): evaluate response at 10-14 weeks 1
• Ustekinumab (anti-IL-12/23): evaluate response at 6-10 weeks 1
• Both have strong recommendations with moderate-quality evidence 1

Critical Pitfalls to Avoid

Never use corticosteroids for maintenance therapy—they are completely ineffective for maintaining remission and cause significant toxicity. 1, 2

Do not use probiotics, omega-3 fatty acids, marijuana, or naltrexone—these have no proven benefit for inducing or maintaining remission. 1

Do not delay biologic therapy in high-risk patients—early aggressive treatment prevents complications, hospitalization, and surgery. 1

Monitor for serious infections—patients on anti-TNF therapy have increased infection risk, including tuberculosis reactivation, invasive fungal infections, and opportunistic infections. Test for latent TB before initiating therapy. 4

Be aware of malignancy risk—hepatosplenic T-cell lymphoma, though rare, has been reported particularly in adolescent/young adult males on combination therapy with thiopurines and anti-TNF agents. 4

Monitoring During Treatment

Objective monitoring is essential (symptoms correlate poorly with inflammation): 2

• Endoscopy for mucosal healing assessment
• CRP and fecal calprotectin levels
• Cross-sectional imaging when indicated
• Therapeutic drug monitoring for biologics 1

Safety monitoring for immunosuppressants: 1

• Complete blood count for neutropenia (azathioprine/mercaptopurine)
• Liver function tests
• TPMT activity before starting thiopurines 1
• Follow BNF/BNFC monitoring guidelines 1

Vaccinations are critical—ensure influenza, pneumococcal, and herpes zoster vaccines are current, but avoid live vaccines in immunosuppressed patients. 6