Management Guidelines for Crohn's Disease
Disease Severity Assessment
Disease severity must be determined using a combination of symptoms, objective inflammatory markers (CRP, fecal calprotectin), and risk factors for complications before initiating therapy. 1
Mild Disease Management
Mild Ileal or Right Colonic Disease
- Oral budesonide 9 mg/day is the first-line therapy for inducing remission 1
- Evaluate symptomatic response between 4-8 weeks to determine need for therapy modification 1
- Budesonide should NOT be used for maintenance therapy due to lack of efficacy 1
- If budesonide fails, escalate to prednisone 40-60 mg/day 1
Mild Colonic Disease
- Sulfasalazine 4-6 g/day can be used for induction in patients with disease limited to the colon 1
- Assess response between 2-4 months 1
- Oral 5-ASA (mesalamine) should NOT be used for induction or maintenance in any location of Crohn's disease 1
Moderate to Severe Disease Management
Corticosteroid Induction
- Prednisone 40-60 mg/day is strongly recommended for moderate to severe disease 1
- Evaluate response between 2-4 weeks 1
- For hospitalized patients with severe disease, use IV methylprednisolone 40-60 mg/day and assess response within 1 week 1
- Corticosteroids must NOT be used for maintenance therapy 1
Biologic Therapy Selection
For moderate to severe Crohn's disease, anti-TNF agents (infliximab, adalimumab) are strongly recommended as first-line biologic therapy for both induction and maintenance of remission. 1
Anti-TNF Agents (First-Line Biologics)
- Infliximab, adalimumab, or certolizumab pegol are recommended over no treatment 1
- Standard infliximab dosing: 5 mg/kg IV every 8 weeks (range 5-10 mg/kg) 2
- Evaluate anti-TNF response between 8-12 weeks 1
- Continue anti-TNF therapy in responders to achieve and maintain complete remission 1
Therapeutic Drug Monitoring and Dose Optimization
- Target infliximab trough levels: 3-7 μg/mL for maintenance therapy 2
- For suboptimal response to anti-TNF induction, consider dose intensification 1, 2
- For loss of response during maintenance, optimize dosing guided by therapeutic drug monitoring 1, 2
- Do NOT switch between anti-TNF agents in patients doing well on current therapy 1
Second-Line Biologics (After Anti-TNF Failure)
Vedolizumab and ustekinumab are both strongly recommended for patients who fail corticosteroids, immunomodulators, or anti-TNF therapy. 1
- Vedolizumab: Evaluate response between 10-14 weeks; continue if symptomatic response achieved 1
- Ustekinumab: Evaluate response between 6-10 weeks; continue if symptomatic response achieved 1
- Both agents have strong recommendations with moderate-quality evidence for maintenance therapy 1
Natalizumab
- Recommend AGAINST natalizumab due to progressive multifocal leukoencephalopathy (PML) risk and availability of safer alternatives 1
Immunomodulator Therapy
Thiopurines (Azathioprine/6-Mercaptopurine)
- Thiopurine monotherapy should NOT be used for induction of remission 1
- Consider for maintenance therapy in patients who relapse within 6-12 months after corticosteroid-induced remission 3
- Can be combined with anti-TNF therapy, though guidelines make no firm recommendation for or against combination therapy 1
Methotrexate
- Alternative immunomodulator for patients intolerant or resistant to thiopurines 4
- Guidelines make no recommendation for or against combining with anti-TNF therapy 1
Therapies NOT Recommended
The following interventions should NOT be used for induction or maintenance of remission:
- Systemically absorbed antibiotics (unless septic complications suspected) 1
- Probiotics 1
- Omega-3 fatty acids 1
- Marijuana 1
- Naltrexone 1
- Enteral nutrition or dietary modification as primary therapy 1
Treatment Algorithm Summary
Assess disease severity using symptoms, objective inflammation, and risk factors 1
Mild ileal/right colonic disease: Start budesonide 9 mg/day → assess at 4-8 weeks → escalate to prednisone if inadequate response 1
Mild colonic disease: Consider sulfasalazine 4-6 g/day → assess at 2-4 months 1
Moderate to severe disease: Start prednisone 40-60 mg/day → assess at 2-4 weeks → transition to anti-TNF therapy (infliximab or adalimumab) for maintenance 1
Anti-TNF failure: Switch to vedolizumab or ustekinumab 1
Optimize dosing using therapeutic drug monitoring (target infliximab trough 3-7 μg/mL) rather than empiric switching 1, 2
Never use corticosteroids or budesonide for maintenance 1
Critical Pitfalls to Avoid
- Do not use 5-ASA products (except sulfasalazine for mild colonic disease) as they lack efficacy 1
- Do not continue corticosteroids long-term for maintenance therapy 1
- Do not switch anti-TNF agents without first attempting dose optimization guided by drug levels 1, 2
- Do not use antibiotics routinely unless infection is suspected 1
- Do not delay biologic therapy in moderate to severe disease, as early intervention prevents complications 1