Medical management of Crohn's disease

The medical management of Crohn's disease is difficult.

Information relating to particular treatment options is also included.Some commonly prescribed drugs in Crohn’s disease are:

• corticosteroids - used in acute disease
• aminosalicylates
• immunosuppressants – thiopurines such as Azathioprine or mercaptopurine, methotrexate
• antibiotics – metronidazole, ciprofloxacin
• cytokine-modulating drugs - anti-TNF-alpha agents
• cholestyramine
• elemental diet (1)

There is clear evidence that stopping smoking reduces the risk of recurrence (2).

With respect to maintaining remission in Crohn's disease, a review concluded that (3):

• azathioprine, infliximab and adalimumab are effective at maintaining remission in Crohn's disease. Natalizumab is also effective, but there are concerns about its potential association with progressive multifocal leukoencephalopathy
• long-term enteral nutritional supplementation, enteric-coated omega-3 fatty acids and intramuscular methotrexate may also be effective but the evidence for these is based on relatively small studies
• available evidence does not support the use of oral 5-aminosalicylates agents, corticosteroids, anti-mycobacterial agents, probiotics or ciclosporin as maintenance therapy in Crohn's disease

Conventional medications for CD include anti-inflammatory drugs, immunosuppressants and corticosteroids. However, if the patient does not respond, or loses response to these first-line treatments, then biologic therapies such as TNF-alpha antagonists including infliximab, certolizumab pegol and adalimumab are then considered for the treatment of CD.

Top-down approaches for CD therapy, including the early use of combination therapy with biologics and immunosuppressives, are increasingly being used and may provide benefit in people with complicated or extensive disease suggestive of an aggressive disease course, and those with poor prognostic factors (1,2)

The aim of treatment should be to induce clinical remission and to maintain remission after medical induction therapy. In clinical practice either:

• “step-up” approach – introduction of new therapies if the first-line or less toxic agents fail (within an appropriate period)
• “top-down” approach – using a potent agent at the early stages of the disease can be used (1).

The European evidence-based consensus guideline has suggested that in some people with mild Crohn's disease, “no treatment” method can be considered as an option (1)

Reference:

• (1) Dignass A et al. The second European evidence-based consensus on the diagnosis and management of Crohn's disease: Current management. Journal of Crohn's and Colitis 2010; 4:28-62
• (2) Tsui JJ, Huynh HQ.Is top-down therapy a more effective alternative to conventional step-up therapy for Crohn's disease?

Ann Gastroenterol. Jul-Aug 2018;31(4):413-424. doi: 10.20524/aog.2018.0253

• (3) Akobeng AK et al. Review article: the evidence base for interventions used to maintain remission in Crohn's disease. Aliment Pharmacol Ther. 2008;27:11