First-Line Treatment for Mild Terminal Ileitis Crohn's Disease (ECCO Guidelines)
For mild terminal ileitis Crohn's disease, oral budesonide 9 mg once daily for 8 weeks is the recommended first-line treatment according to ECCO guidelines. 1, 2
Treatment Rationale and Evidence
Budesonide is specifically indicated for mild to moderate ileal and/or right colonic Crohn's disease, achieving remission rates of approximately 51% at 8 weeks. 2, 3 This locally active corticosteroid provides comparable efficacy to systemic prednisolone (51% vs 52.5% remission) but with significantly fewer systemic side effects due to high first-pass hepatic metabolism. 3
Treatment Protocol
Initial therapy:
- Start budesonide 9 mg orally once daily 1, 2
- Continue for 8 weeks 2, 3
- Taper over 1-2 weeks once remission is achieved 2, 3
Response assessment timeline:
- Evaluate symptomatic response between 4-8 weeks to determine need for therapy modification 2, 3
- Use objective measures (fecal calprotectin, CRP, endoscopy) rather than symptoms alone 2
Alternative and Ineffective Options
What NOT to use for terminal ileitis:
- Mesalamine (5-ASA) is NOT recommended for Crohn's disease at any location, as it shows no significant benefit over placebo for induction or maintenance of remission 1, 3, 4
- Sulfasalazine is only appropriate for colonic disease, not ileal disease 1, 2
- Antibiotics have no established role in routine treatment of mild Crohn's disease 1
When to Escalate Therapy
Indications for escalation to moderate-to-severe treatment:
- Failure to respond by 4-8 weeks 2
- CDAI score >220 2
- Presence of high-risk features (deep ulcerations, strictures, fistulas, prior resections) 2
- Steroid-dependent disease (requiring repeated courses) 2, 3
Maintenance Considerations
Critical caveat: Budesonide should NOT be used for maintenance therapy in Crohn's disease. 1 For patients who relapse after initial budesonide-induced remission, consider:
- Thiopurines (azathioprine or 6-mercaptopurine) for steroid-dependent patients 2, 3
- Anti-TNF biologics reserved for those progressing to moderate-to-severe disease or with high-risk features 2
Common Pitfalls to Avoid
- Never use systemic corticosteroids for maintenance therapy due to serious adverse effects including increased infection risk, osteoporosis, diabetes, and Cushing syndrome 3
- Do not prescribe mesalamine for terminal ileitis based on its efficacy in ulcerative colitis—the evidence clearly shows no benefit in Crohn's disease 1, 3, 4
- Avoid empiric dose escalation without objective documentation of disease activity 5
- Do not delay assessment beyond 8 weeks if symptoms persist, as this represents treatment failure requiring escalation 2, 3