Medical management of Crohn's disease

The medical management of Crohn's disease is difficult and any pharmacotherapeutic interventions should be managed by specialists who are experts in this condition. (1)

Several agents are now available for the medical treatment of Crohn's including: (2)

Locally active corticosteroids

Systemic corticosteroids

Thiopurines (e.g., azathioprine, mercaptopurine)

Methotrexate

Biological therapies (such as tumour necrosis factor [TNF]-alpha inhibitors, integrin receptor antagonists, interleukin [IL]-12/23 antagonists)

Janus kinase (JAK) inhibitors (e.g., upadacitinib)

There is clear evidence that stopping smoking reduces the risk of recurrence (1).

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 immunosuppressive drugs, 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 (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.

References:

1. NICE. Crohn’s disease: management. NICE guideline NG129. Published May 2019
2. Torres J, Bonovas S, Doherty G, et al. ECCO guidelines on therapeutics in Crohn's disease: medical treatment. J Crohns Colitis. 2020 Jan 1;14(1):4-22.
3. 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