Treatment escalation and de-escalation decisions in Crohn’s disease: Delphi consensus recommendations from Japan, 2021

Abstract

Background We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn’s disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. Methods PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. Results Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. Conclusions These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.

A novel location classification system for Crohn’s disease based on small bowel involvement: a better predictor of disease progression

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Best Practice for Therapeutic Drug Monitoring of Infliximab: Position Statement from the International Association of Therapeutic Drug Monitoring and Clinical Toxicology

“…18,19 The conflicting results from these RCTs regarding the benefit of TDM in IBD have hindered the widespread adoption of TDM in clinical guidelines (see Tables, Supplemental Digital Content 1, http://links.lww.com/TDM/A735 and http://links.lww.com/ TDM/A736). [20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] The American Gastroenterological Association conditionally recommended reactive TDM based on very low-quality evidence. 21 The European Crohn's and Colitis Organization guidelines recommend neither proactive nor reactive TDM.…”

Intestinal strictures in Crohn's disease: An update from 2023

“…Endoscopy plays an important role in the management of intestinal disease and allows direct visualization of the narrowing bowel. It is recommended to complete colonoscopy, even if imaging tests, such as MRE, are negative, especially when patients have obstructive symptoms, and to perform endoscopic balloon dilatation if necessary 62 . However, before performing video capsule endoscopy, it is recommended to use the patency capsule procedure for ruling out small bowel stenosis 61 .…”

“…Currently, the most commonly used diagnostic methods are magnetic resonance imaging (MRI) and computed tomography (CT) since they are non‐invasive and quickly evaluate active transmural inflammation and detect intestinal strictures (Table 2 ). 50 , 51 , 53 , 54 , 55 , 57 , 59 , 60 , 62 Comparing CT and MRE, a previous study suggested that the latter one is free of ionising radiation and therefore has become the most widely applied method for stricture differentiation. 66 Novel MRI techniques, such as magnetization transfer MRI (MTR) and texture analysis (TA), show promise in assessing intestinal fibrosis.…”