What is the prognosis and current management for advanced Crohn's disease?

From the Guidelines

The current management of advanced Crohn's disease prioritizes a combination of biologics, such as anti-TNF agents, anti-integrins, or IL-12/23 inhibitors, alongside immunomodulators and lifestyle modifications to achieve deep remission and prevent disease progression. The prognosis for advanced Crohn's disease varies widely among patients, with many experiencing periods of remission interspersed with flares, though most can achieve good quality of life with appropriate management 1. Current management focuses on a combination of medications, lifestyle modifications, and sometimes surgery. First-line medical therapy typically includes biologics such as anti-TNF agents (infliximab 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks; adalimumab 160 mg initially, 80 mg at week 2, then 40 mg every other week), anti-integrins (vedolizumab 300 mg IV at weeks 0,2, and 6, then every 8 weeks), or IL-12/23 inhibitors (ustekinumab ~6 mg/kg IV induction, then 90 mg SC every 8 weeks) 1. These may be combined with immunomodulators like azathioprine (2-3 mg/kg/day) or methotrexate (25 mg weekly) 1. Some key points to consider in the management of advanced Crohn's disease include:

• The use of biologic therapy, with or without immunomodulators, as the primary approach for inducing and maintaining remission 1.
• The selection of biologic agents based on patient-specific factors, including disease severity, extent, and prior treatment response 1.
• The importance of regular monitoring through colonoscopy, imaging, and laboratory tests to assess disease activity and treatment response 1.
• The role of surgery in managing complications such as strictures, fistulas, or abscesses that do not respond to medical therapy 1.
• The need for a multidisciplinary approach involving gastroenterologists, surgeons, nutritionists, and mental health professionals to provide optimal care 1. The goal of treatment is to achieve deep remission (clinical, biochemical, and endoscopic healing) to prevent disease progression and complications, with the most recent and highest quality evidence supporting the use of combination therapy with biologics and immunomodulators as the most effective approach 1.

From the FDA Drug Label

RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy RENFLEXIS is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn's disease. The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adults with moderately to severely active Crohn's disease or fistulizing Crohn's disease HUMIRA is a tumor necrosis factor (TNF) blocker indicated for: treatment of moderately to severely active Crohn’s disease in adults and pediatric patients 6 years of age and older. Adults: 160 mg on Day 1 (given in one day or split over two consecutive days); 80 mg on Day 15; and 40 mg every other week starting on Day 29

The prognosis for advanced Crohn's disease is variable and depends on several factors, including the severity of the disease, the presence of complications, and the response to treatment. The current management for advanced Crohn's disease includes:

• Medications: such as infliximab (RENFLEXIS) and adalimumab (HUMIRA), which are tumor necrosis factor (TNF) blockers that can help reduce inflammation and induce and maintain clinical remission.
• Dosing: The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter. The recommended dose of HUMIRA is 160 mg on Day 1,80 mg on Day 15, and 40 mg every other week starting on Day 29.
• Treatment goals: The goal of treatment is to reduce signs and symptoms, induce and maintain clinical remission, and improve quality of life. Key considerations in the management of advanced Crohn's disease include:
• Monitoring: Regular monitoring for signs and symptoms of infection, malignancy, and other complications is crucial.
• Adjusting treatment: Treatment may need to be adjusted based on the patient's response and the presence of any complications or side effects.
• Surgery: In some cases, surgery may be necessary to treat complications such as bowel obstruction, fistulas, or abscesses. 2 3

From the Research

Prognosis for Advanced Crohn's Disease

• The prognosis for advanced Crohn's disease is complex and depends on various factors, including the severity of the disease, the presence of complications, and the response to treatment 4.
• Uncontrolled inflammation can lead to long-term complications, such as fibrotic strictures, enteric fistulae, and intestinal neoplasia, which can significantly impact the quality of life and prognosis of patients with advanced Crohn's disease 4.

Current Management for Advanced Crohn's Disease

• The current management of advanced Crohn's disease involves a multi-faceted approach, including pharmacological therapy, surgery, and lifestyle modifications 4, 5.
• Pharmacological therapy may include biologics, such as vedolizumab, adalimumab, and infliximab, as well as immunomodulators and small molecule therapies 6, 7, 8.
• Combination therapy, such as the combination of vedolizumab, adalimumab, and methotrexate, may be effective in inducing and maintaining remission in patients with advanced Crohn's disease 6.
• Surgery may be necessary in some cases, particularly for patients with complications such as bowel obstruction, abscesses, or fistulae 4, 5.

Treatment Options for Advanced Crohn's Disease

• Biologics, such as infliximab, adalimumab, and vedolizumab, have been shown to be effective in inducing and maintaining remission in patients with advanced Crohn's disease 6, 8.
• Immunomodulators, such as azathioprine and methotrexate, may also be used in combination with biologics to enhance their efficacy 6, 8.
• Small molecule therapies, such as Janus kinase inhibitors, may also be effective in treating advanced Crohn's disease 7.
• Dual advanced therapies, such as the combination of biologics and small molecule therapies, may be considered for patients with refractory disease 7.