Medical Management of Crohn Disease

Introduction

Crohn disease (CD) is a chronic, relapsing, idiopathic inflammatory condition that primarily affects the gastrointestinal tract. The severity and location of CD are variable. CD, a transmural inflammation of the bowel characterized by skip lesions that may involve any section of the gastrointestinal tract, is sometimes complicated by strictures and fistula formation. In about 50% of cases, CD affects the terminal ileum and colon; in 20% of cases, it affects the colon only; and in 30% of cases, it affects the small bowel only. Perianal complications develop in about 20% of persons with CD.

Treatment paradigms for CD are rapidly evolving as newer agents become available. Treatment with 5-aminosalicylates (5-ASA) is no longer recommended, and anti–tumor necrosis factor (TNF) therapies are initiated earlier in the course of disease to induce mucosal healing. The primary treatment goal is induction and maintenance of steroid-free remission while minimizing drug toxicity. This target has been associated with a better quality of life and a lower likelihood of requiring hospitalizations or surgery. “Deep remission,” defined as both clinical and endoscopic remission, might become the ultimate therapeutic goal in the future.

Medical Therapies

Multiple options exist for the medical treatment of CD. The choice of therapy is guided by the efficacy of any given agent in inducing and/or maintaining remission, as well as by the severity and extent of the disease. Serious adverse effects of medical treatment are rare, but risks and benefits should be carefully weighed in selecting the appropriate treatment strategy.

5-Aminosalicylates

5-ASA drugs, such as mesalamine and sulfasalazine, are no longer recommended for the treatment of CD. Sulfasalazine alone has shown moderate benefit in treating active disease, but it has not been shown to be effective in maintaining remission. Nevertheless, many physicians prescribe ASA drugs for mild CD because of their low toxicity, low cost, and familiarity. In particular, mesalamine (Pentasa), a controlled-release formulation of 5-ASA, is a favorite drug for CD involving the small bowel and colon because it releases approximately 50% of 5-ASA in the small intestine and the remaining 50% in the colon. Mesalamine suppositories and enemas are also used for distal left-sided disease. 5-ASA agents have a relatively safe toxicity profile. Kidney function may be checked annually because of a low risk of renal insufficiency. Interstitial nephritis is considered an idiosyncratic reaction and is not dose dependent. Rarely, a hypersensitivity reaction can occur, causing worsening abdominal pain, diarrhea, or hematochezia, which should prompt discontinuation of the drug. Although many physicians and patients still elect to use 5-ASA, it has not been proved that these agents affect the course of CD.

Antibiotics

No strong evidence exists to support the use of antibiotics in persons with active CD. However, antibiotics may be beneficial in treating suppurative disease, perianal complications, or hospitalized patients who have signs of infection. A common practice is to prescribe a 2-week course of ciprofloxacin, 500 mg by mouth twice a day, and metronidazole, 500 mg by mouth twice a day.

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