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Corticosteroids are effective in inducing remission in Crohn’s disease but is ineffective at maintaining remission (1)
Acute severe exacerbations are treated with intravenous hydrocortisone:
- for example, 100 mg hydrocortisone iv 8 hourly for two days
The intravenous steroids are replaced by oral prednisolone and patients are weaned off steroids as symptoms allow. The side-effects of steroids do not permit their use as a maintenance treatment. In less severe exacerbations then oral steroids may be used from the onset of management.
Prescribing regimens are not standardised, but a starting dose of 40 mg per day reducing to zero over 5 weeks, taken in addition to a 5-ASA agent, is a reasonable reflection of common practice in the use of oral steroids in inducing remission in Crohn's disease (and ulcerative colitis) (2). Relapses are more frequent if a short course of steroids is used (for example as may be used in exacerbations of asthma) (2).
Oral modified release budesonide may offer good luminal anti-inflammatory effects with reduced systemic absorption.
With respect to inducing remission in Crohn's disease NICE state (3):
Inducing remission in Crohn's disease
- monotherapy with a conventional glucocorticoid (prednisolone, methylprednisolone or intravenous hydrocortisone) should be considered to induce remission in people with a first presentation or a single inflammatory exacerbation of Crohn's disease in a 12-month period
- consider enteral nutrition as an alternative to conventional glucocorticoid to induce remission for:
- children in whom there is concern about growth or side effects, and
- young people in whom there is concern about growth
- budesonide * should be considered for a first presentation or single inflammatory exacerbation in a 12-month period for people:
- who have one or more of distal ileal, ileocaecal or right-sided colonic disease, AND
- if conventional glucocorticoids are contraindicated, or if the person declines or cannot tolerate them
- explain that budesonide is less effective than a conventional glucocorticoid, but may have fewer side effects
- consider aminosalicylate ** treatment
- for a first presentation or single inflammatory exacerbation in a 12-month period if conventional glucocorticoids are contraindicated, or if the person declines or cannot tolerate them
- explain that aminosalicylates are less effective than a conventional glucocorticoid or budesonide but may have fewer side effects than a conventional glucocorticoid
- do not offer budesonide or aminosalicylate treatment for severe presentations or exacerbations
- do not offer azathioprine, mercaptopurine or methotrexate as monotherapy to induce remission
- in some instances more than a single therapy will be required to induce remission (termed 'add-on' treatment)
- add-on treatment in Crohn's disease (3):
- azathioprine or mercaptopurine should be considered as an add-on to a conventional glucocorticosteroid or budesonide to induce remission of Crohn's disease if:
- there are two or more inflammatory exacerbations in a 12-month period,
- or the glucocorticosteroid dose cannot be tapered
- thiopurine methyltransferase (TPMT) activity should assessed before offering azathioprine or mercaptopurine
- do not offer azathioprine or mercaptopurine if TPMT activity is deficient (very low or absent). Consider azathioprine or mercaptopurine at a lower dose if TPMT activity is below normal but not deficient (according to local laboratory reference values)
- consider addtion of methotrexate to a conventional glucocorticosteroid or budesonide to induce remission in people who cannot tolerate azathioprine or mercaptopurine, or in whom TPMT activity is deficient, if:
- there are two or more inflammatory exacerbations in a 12-month period, or
- the glucocorticosteroid dose cannot be tapered
- Infliximab and adalimumab
- infliximab and adalimumab, within their licensed indications, are recommended as treatment options for adults with severe active Crohn's disease whose disease has not responded to conventional therapy (including immunosuppressive and/or corticosteroid treatments), or who are intolerant of or have contraindications to conventional therapy. Infliximab or adalimumab should be given as a planned course of treatment until treatment failure (including the need for surgery), or until 12 months after the start of treatment, whichever is shorter
- severe active Crohn's disease
- defined as very poor general health and one or more symptoms such as weight loss, fever, severe abdominal pain and usually frequent (3-4 or more) diarrhoeal stools daily
- people with severe active Crohn's disease may or may not develop new fistulae or have extra-intestinal manifestations of the disease
- this clinical definition normally, but not exclusively, corresponds to a Crohn's Disease Activity Index (CDAI) score of 300 or more, or a Harvey-Bradshaw score of 8 to 9 or above.
* although use is common in UK clinical practice, budesonide is not specifically licensed for children and young people
** although use is common in UK clinical practice, mesalazine, olsalazine and balsalazide are not licensed for this indication