Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease

Abstract

Background & Aims Crohn’s disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. Methods We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. Results The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. Conclusions Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.

Azathioprine-induced severe anemia potentiated by the concurrent use of allopurinol

“…For example, the Canadian Gastroenterology Guideline recommends TPMT testing for patients with inflammatory bowel disease who are starting azathioprine to help guide dosage and identify patients at risk for severe toxicity. 13 …”

Evaluation of pharmacotherapy recommendations in guidelines for inflammatory bowel disease

“…The ideal guidelines for IBD are based on high‐quality evidence that helps clinicians and policymakers decide how to better assess and treat IBD. However, there are differences in recommendations for the treatment of IBD with different drugs at present, 3‐13 which makes users of the guidelines unsure of how to select and use the recommendations.…”

Anémie grave induite par l’azathioprine et potentialisée par l’emploi concomitant d’allopurinol

“…La recherche de mutations du gène codant pour la TPMT devrait être envisagée dans certaines situations cliniques. Par exemple, les lignes directrices de l'Association canadienne de gastro-entérologie recommandent un test chez les patients atteints de maladie inflammatoire intestinale qui commencent l'azathioprine afin de guider la posologie et de repérer les patients courant un risque de toxicité grave 13 . Correspondance : Lorenzo Madrazo, lmadrazo@uwo.ca La section Études de cas présente de brefs rapports de cas à partir desquels des leçons claires et pratiques peuvent être tirées.…”