Treatment Algorithms for Crohn’s Disease

Abstract

Background: Treatment of Crohn's disease (CD) patients is complex as therapy choices depend on a variety of factors, such as location and severity of inflammation, disease behavior (inflammatory, stricturing or penetrating) but also comorbidities, extra-intestinal manifestations, the patient's age, and previous therapies. Subsequently, the choice of treatment should be tailored to the individual patient. Summary: This article gives the reader therapy algorithms as a guide through different CD scenarios to support the physician's decision making. New compounds introduced in CD therapy in recent years justify such an update on standard approaches. Ustekinumab and vedolizumab and their positions within the treatment options are discussed. Fistulizing perianal disease and postoperative medical prophylaxis are depicted in separate chapters with own algorithms. Key Messages: In recent years, a variety of new drugs became available to treat patients with CD-especially those who are antitumor necrosis factor (TNF) experienced with ongoing inflammation. The definitive role of vedolizumab and ustekinumab is not yet fully clarified. However, with the advantage of good safety profiles over TNF-inhibitors, these drugs will be more frequently used in the near future, also as first-line biologicals, compared to TNF-inhibitors. Concerning treatment of fistulizing disease, the knowledge of the exact anatomy of the fistula is of major importance. An interdisciplinary discussion involving gastroenterologists, surgeons, and in some cases gynecologists may help to optimize the treatment plan. Regarding the postsurgical setting in CD patients, according to the very recent Cochrane Network meta-analysis, mesalazine should be at least positioned equivalent to thiopurines and TNF-inhibitors, as shown in our algorithm.

Nutritional Therapy Strategies in Pediatric Crohn’s Disease

“…CD is characterized by the excessive infiltration of leukocytes into the inflamed mucosa and a high level of secreted proinflammatory cytokines [17,18]. Thus, medication regimens are focused on the use of immunomodulators or -suppressants (such as corticosteroids, methotrexates, thiopurines, and biologicals such antitumor necrosis factor alpha (TNFα)) to dampen immune system activity [9,19]. However, multiple side effects, such as the increased risk of infections and malignancy, are associated with the use of immuno-modulators and -suppressants [9].…”

Medical, ethical, and legal aspects of hematopoietic stem cell transplantation for Crohn’s disease in Brazil

“…The treatment is complex and depends on the patient's assessment criteria and severity of the patient's condition[ 10 ]. The criteria used for this decision are, among others, the age at diagnosis of the disease, location and behavior, and type of lesion observed, data that make up the Montreal Classification[ 11 ].…”

“…Several treatment algorithms exist, from bottom-up from gradual progression to the use of biological agents as the last of the scale to the opposite approach, top-down with the utilization of biological agents first. Concerning biological agents, anti-TNF alpha (infliximab, adalimumab, and certolizumab pegol), the first described and most used as a rule to start treatment and in the absence of primary or secondary response may be substituted by other biologicals such as anti-alpha four integrin (vedolizumab) and anti-leucine 12/23 (ustekinumab)[ 10 ]. However, the sequence described for the use of biologicals is controversial[ 10 ].…”

“…Concerning biological agents, anti-TNF alpha (infliximab, adalimumab, and certolizumab pegol), the first described and most used as a rule to start treatment and in the absence of primary or secondary response may be substituted by other biologicals such as anti-alpha four integrin (vedolizumab) and anti-leucine 12/23 (ustekinumab)[ 10 ]. However, the sequence described for the use of biologicals is controversial[ 10 ]. Current treatment results are not entirely satisfactory because prescription drug treatment is chronic, some patients become refractory, and recurrent surgical procedures compel patients to seek alternative treatments, including autologous hematopoietic stem cell transplantation (HSCT).…”

Medikamentöse Therapie der chronisch entzündlichen Darmerkrankungen (CED)

“…Ziel neuerer Studien ist damit neben der reinen Wirksamkeitsanalyse von Medikamenten zunehmend auch die Evaluation von geeigneten Algorithmen zur Steuerung einer auf den Patienten zugeschnittenen individuellen Pharmako-und supportiven Therapie [35].…”