Induction and Maintenance in Luminal/Fistulizing Crohn's Disease
Induction and Maintenance in Luminal/Fistulizing Crohn's Disease
What are the current recommended regimens for induction and maintenance in patients with luminal and fistulizing Crohn's disease?
Response from Bret A. Lashner, MD
Director, Center for Inflammatory Bowel Disease, Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, Ohio
The only medications approved by the US Food and Drug Administration for the treatment of patients with Crohn's disease are budesonide for mildly to moderately active disease and infliximab for moderately to severely active disease. Both drugs also are approved for maintenance therapy.
For patients with mildly active Crohn's disease, budesonide is at least 60% effective in inducing remission, especially among those with ileocolonic disease. In patients with principally colonic disease, a 5-aminosalicylic acid product, such as sulfasalazine, will often induce remission. For maintenance of medically induced remission, budesonide, 5-aminosalicylic acid (for colonic disease), and the immunosuppressive agents, 6-mercaptopurine and azathioprine, are effective alternatives.
For patients with moderately to severely active disease, remission can be induced with prednisone, methotrexate, or infliximab. Each of these agents is effective, and each has a different adverse-effect profile that needs to be discussed and reviewed in detail with the patient before a therapeutic choice is made. Drugs that are known to maintain a medically induced remission in these patients include 6-mercaptopurine, azathioprine, methotrexate, and infliximab. The choice of agent depends on the benefits, toxicities, and cost.
Patients with fistulizing Crohn's disease most often need to be treated by both a gastroenterologist and a colorectal surgeon. The surgeon should establish drainage for any sepsis. The immunosuppressive agents 6-mercaptopurine or azathioprine, in addition to broad-spectrum antibiotics, are first-line therapies for fistulizing disease. Therapy with the biologic agent infliximab, in addition to immunosuppressive and antibiotic therapy, is often needed in this setting. Maintenance of remission for fistulizing disease involves at least an immunosuppressive agent, and often involves the continuation of infliximab therapy. Steroids should be avoided in patients with fistulizing disease.
Question
What are the current recommended regimens for induction and maintenance in patients with luminal and fistulizing Crohn's disease?
Response from Bret A. Lashner, MD
Response from Bret A. Lashner, MD
Director, Center for Inflammatory Bowel Disease, Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, Ohio
The only medications approved by the US Food and Drug Administration for the treatment of patients with Crohn's disease are budesonide for mildly to moderately active disease and infliximab for moderately to severely active disease. Both drugs also are approved for maintenance therapy.
For patients with mildly active Crohn's disease, budesonide is at least 60% effective in inducing remission, especially among those with ileocolonic disease. In patients with principally colonic disease, a 5-aminosalicylic acid product, such as sulfasalazine, will often induce remission. For maintenance of medically induced remission, budesonide, 5-aminosalicylic acid (for colonic disease), and the immunosuppressive agents, 6-mercaptopurine and azathioprine, are effective alternatives.
For patients with moderately to severely active disease, remission can be induced with prednisone, methotrexate, or infliximab. Each of these agents is effective, and each has a different adverse-effect profile that needs to be discussed and reviewed in detail with the patient before a therapeutic choice is made. Drugs that are known to maintain a medically induced remission in these patients include 6-mercaptopurine, azathioprine, methotrexate, and infliximab. The choice of agent depends on the benefits, toxicities, and cost.
Patients with fistulizing Crohn's disease most often need to be treated by both a gastroenterologist and a colorectal surgeon. The surgeon should establish drainage for any sepsis. The immunosuppressive agents 6-mercaptopurine or azathioprine, in addition to broad-spectrum antibiotics, are first-line therapies for fistulizing disease. Therapy with the biologic agent infliximab, in addition to immunosuppressive and antibiotic therapy, is often needed in this setting. Maintenance of remission for fistulizing disease involves at least an immunosuppressive agent, and often involves the continuation of infliximab therapy. Steroids should be avoided in patients with fistulizing disease.