What is the recommended treatment for a patient experiencing a Crohn's disease flare-up?

Treatment of Crohn's Disease Flare-Up

For a Crohn's disease flare-up, start oral prednisone 40-60 mg daily for moderate to severe disease, or budesonide 9 mg daily for mild to moderate disease limited to the ileum and right colon, with response evaluation at 2-4 weeks to determine if escalation to biologic therapy is needed. 1, 2

Initial Assessment and Disease Categorization

Before selecting treatment, determine disease severity (mild, moderate, or severe) based on clinical symptoms, inflammatory markers (CRP, fecal calprotectin), and disease location. 1 Disease location—whether ileal, ileocolonic, or colonic—directly impacts which corticosteroid formulation to use. 1

First-Line Corticosteroid Therapy

For Mild to Moderate Disease (Ileal/Right Colonic)

• Budesonide 9 mg daily is the preferred initial therapy for disease limited to the ileum and/or right colon. 1, 2
• Evaluate response between 4-8 weeks. 2
• Budesonide has lower systemic bioavailability, resulting in fewer dermatologic and metabolic side effects compared to systemic steroids, though it is somewhat less potent. 3, 4

For Moderate to Severe Disease

• Prednisone 40-60 mg daily is strongly recommended as first-line therapy. 1, 2
• Evaluate response between 2-4 weeks. 1, 2
• Prednisone induces remission in 60-83% of patients with moderate to severe disease. 2
• Taper gradually over 8 weeks once remission is achieved, as more rapid reduction increases early relapse risk. 1

For Severe Disease Requiring Hospitalization

• IV methylprednisolone 40-60 mg daily (typically 40 mg every 8 hours) provides more predictable drug delivery when GI absorption is compromised. 1
• Evaluate response within 1 week to determine if therapy modification is needed. 1
• Consider joint medical-surgical management for severe presentations. 1

Critical Pitfall: Never Use Steroids for Maintenance

Corticosteroids are completely ineffective for maintaining remission and should never be used beyond the acute flare. 1, 3, 5 Nearly 50% of patients who initially respond will become steroid-dependent or relapse within one year. 3, 4 Steroids do not heal mucosal lesions and carry unacceptable long-term toxicity risks including bone loss, glucose intolerance, glaucoma, and serious infections. 3

When to Escalate to Biologic Therapy

Immediate Biologic Initiation (First-Line)

For patients with high-risk features, start anti-TNF therapy immediately rather than steroids: 1

• Stricturing or penetrating disease
• Perianal fistulas
• Age under 40 years at diagnosis
• Need for steroids at diagnosis

Biologic Escalation After Steroid Trial

Switch to biologics if: 1, 2

• Inadequate response to steroids at 2-4 weeks
• Steroid dependency develops (inability to taper without relapse)
• Steroid resistance (failure to respond)
• Need for repeated steroid courses

Biologic Options

• Anti-TNF agents (infliximab, adalimumab): Strongly recommended for moderate to severe disease with poor prognostic factors. 1 For adalimumab in adults: 160 mg on Day 1,80 mg on Day 15, then 40 mg every other week starting Day 29. 6
• Vedolizumab: Recommended for patients who fail corticosteroids, thiopurines, methotrexate, or anti-TNF therapy; evaluate response at 10-14 weeks. 7, 1
• Ustekinumab: Recommended for moderate to severe disease failing other therapies; evaluate response at 6-10 weeks. 7, 1

Steroid-Sparing Maintenance Strategy

After achieving remission with steroids, transition to maintenance therapy: 2

• Thiopurines (azathioprine/mercaptopurine) or methotrexate for selected patients without high-risk features
• Biologic therapy should be continued indefinitely in responders—this is the preferred maintenance approach for most patients with moderate to severe disease 1

Combination Therapy Considerations

When starting anti-TNF therapy, consider combining with thiopurine or methotrexate to improve pharmacokinetic parameters and reduce immunogenicity, though this must be balanced against increased infection risk. 7 During the COVID-19 pandemic context, monotherapy with adalimumab was suggested to promote home care and lower immunogenicity risk relative to infliximab. 7

Adjunctive Measures

• Continue aminosalicylates if already prescribed, though they have limited efficacy in Crohn's disease. 1, 6
• Avoid long-term opioid use due to association with poor outcomes. 1
• For patients with concurrent pain and depression, tricyclic antidepressants may offer dual benefits. 1, 8

Therapies NOT Recommended

Do not use probiotics, omega-3 fatty acids, marijuana, or naltrexone—these lack evidence for inducing or maintaining remission. 7, 1