Mild to moderate Crohn's disease – defining the basis for a new treatment algorithm

Abstract

Summary Previously, clinicians have had few choices in treating mild to moderate Crohn's disease. They currently treat these Crohn's disease patients with oral mesalamine and antibiotics. This treatment approach is based on the safety of these agents, and the perception that they are effective. This perception regarding efficacy may be influenced by publication bias. This review examines the efficacy and safety data of the conventional corticosteroids, mesalamine, sulfasalazine, budesonide and antibiotics for inducing the remission of mild to moderate Crohn's disease from randomized controlled trials, and proposes an evidence‐based treatment approach. Sulfasalazine has demonstrated modest efficacy when Crohn's disease is confined to the colon. Mesalamine has no clear benefit over placebo in treating active Crohn's disease. Conventional corticosteroids effectively induce remission but are associated with unwanted adverse effects. Budesonide has similar efficacy to conventional steroids with far fewer adverse effects. Antibiotics have not consistently demonstrated efficacy. We propose a new evidence‐based approach which suggests inducing remission of mild to moderate Crohn's disease with budesonide 9 mg/day for patients with ileal and/or right colonic involvement; sulfasalazine for those with disease limited to the colon; and conventional steroids for high disease activity, those who failed budesonide and those with left‐sided disease who are allergic or intolerant to sulfasalazine.

Perfil dos pacientes ambulatoriais com doenças inflamatórias intestinais

“…The most frequently prescribed medication in the treatment of CD was immunosuppressive, followed by corticosteroid. These medications are also well established in its use and maintenance of disease remission, and corticosteroids play major role in the acute phase 11,12 . Due to the time of onset of action of immunosuppressants (about three months) corticosteroids are often used during this phase, which may explain the significant association between prevalence of steroids and immunosuppressive 10,16 .…”

Appropriate Treatment for Crohn’s Disease: Methodology and Summary Results of a Multidisciplinary International Expert Panel Approach – EPACT

“…These panel recommendations about 5-ASA compounds and steroids are in accordance with a recent expert opinion outside Europe [16]. Immunosuppressive therapy and infliximab were rated inappropriate by the panel, which considered that the risks of these medications outweighed the benefits in milder forms of the disease.…”

Mild-to-Moderate Active Luminal Crohn’s Disease

“…Budesonide has later been inserted in this progressive scheme, just before conventional steroids are considered. A more evidence-based approach that takes into account disease location and the lack of demonstrated efficacy of mesalazine has been proposed [48]. In this approach SFS 3–6 g/day is recommended as first-line therapy for colonic CD, and budesonide 9 mg/day for 8–16 weeks, followed by a tapering schedule over 2–4 weeks by 3 mg increments, for disease located in the terminal ileum and right colon.…”