Crohn's disease (CD), as a chronic inflammatory intestinal disease, can cause irreversible damage to the intestines and seriously affect the quality of life of patients. Therefore, the European Organization for Crohn's Disease and Colitis (ECCO) updated its CD drug treatment guidelines in 2020 and adopted recommendations for quantitative grading to better guide CD drug treatment.
1. Induce remission
Mild-moderate CD
5-Aminosalicylic acid preparations
Mesalazine for CD-induced relief is not recommended (weak recommendation, medium-quality evidence).
Budesonide
Budesonide-induced remission is recommended in patients with active mild to moderate CD whose lesions are limited to the ileum or ascending colon (highly recommended, medium-quality evidence).
antibiotic
Antibiotics are indicated for the treatment of CD-complicated sepsis, but antibiotics are not specifically recommended for the treatment of colonic CD.
Moderate-severe CD
Systemic glucocorticoids
Systemic glucocorticoids are recommended for clinical response and clinical response in patients with moderately to severely active CD (see table Weak Recommendation, Medium-Quality Evidence).
Immunosuppressants - thiopurine
Thiopurine monotherapy is not recommended as induction of remission in patients with moderate to severe colonic CD (weak recommendation, very low-quality evidence).
Immunosuppressants - methotrexate
There is no agreement on the use of methotrexate to induce CD remission, so this consensus has decided not to make recommendations. Based on the current evidence, the use of methotrexate to induce clinical remission cannot be recommended. But when alternatives (including surgery) are not available, methotrexate can be used as an option in hormone-dependent patients with moderate to severe CD. Patients planning to try to conceive must consider discontinuing methotrexate.
Monoclonal antibodies
Tumor necrosis factor (TNF) inhibitors (infliximab, adalimumab, and cestuzumab) are recommended as induction of remission in patients with moderate to severe Crohn's disease who do not respond to conventional treatment (strong recommendation, medium-quality evidence).
When to use biologics is currently controversial. It is currently recommended that patients with adverse prognostic factors (eg, fistula, extensive lesions, deep ulceration, presence of complications) benefit from earlier use of TNF-α inhibitors (including reduced risk of surgery, hospitalization rates, and disease-related complications). Although the findings came from post-mortem analysis of clinical trials, TNF-α inhibitors may be more effective when used early in the disease (within the first 2 years after diagnosis).
Compared with adalimumab monotherapy, adalimumab plus mercaptopurines are not recommended for clinical response and clinical response (weak recommendation, moderate-quality evidence).
For patients with moderate to severe CD who have underreacted traditional treatment, infliximab plus mercaptopurines for remission induction is recommended (highly recommended, moderate-quality evidence).
For patients with moderate to severe CD who have underreacted traditional therapy and/or anti-TNF therapy, ussenuzumab-induced remission therapy is recommended (highly recommended, high-quality evidence).
For patients with moderate to severe CD who have underreacted conventional and/or anti-TNF therapy, the use of vedolizumab for remission induction is recommended (highly recommended, medium-quality evidence).
For patients with moderate to severe active-stage fistula-type CD who fail to fight TNF, treatment with ushinumab or vedozumab is recommended (weak recommendation, very low-quality evidence).
2. Maintain remission
5-ASA preparation
Oral formulations of 5-aminosalicylic acid are not recommended for maintenance therapy after induction of remission in PATIENTS with CD (strong recommendation, low-quality evidence).
Immunosuppressant - azathioprine
Azathioprine may be recommended for maintenance of remission in patients with hormone-dependent CD (strong recommendation, medium-quality evidence).
Early use of azathioprine for maintenance of remission in patients with newly diagnosed CD is not recommended (weak recommendation, low-quality evidence).
Parenteral route administration of methotrexate is recommended for maintenance of remission in patients with hormone-dependent CD (weak recommendation, medium-quality evidence).
In CD patients with TNF inhibitors to achieve remission, the use of the same TNF inhibitor is recommended for maintaining remission (strong recommendation, moderate-quality evidence).
Vedolizumab is recommended for maintenance therapy in patients with moderate to severe CD who use vedolizumab to induce remission (highly recommended, moderate-quality evidence).
Usenumab is recommended for maintenance therapy in patients with moderate to severe CD who use using using uszunuzumab to induce remission (highly recommended, moderate-quality evidence).
Maintain a strategy
In CD patients who responded after anti-TNF drug therapy, there is currently insufficient evidence to support or oppose the proactive use of therapeutic drug monitoring (TDM) to improve clinical outcomes (weakly recommended, medium-quality evidence).
For CD patients with no response to TNF inhibitors, there is currently insufficient evidence to support or oppose passive TDM surveillance to improve clinical outcomes (weakly recommended, low-quality evidence).
For CD patients with Thiopurines who achieve long-term maintenance remission, it is recommended to continue thiopurine therapy because of the higher risk of recurrence after discontinuation (weak recommendation, low-quality evidence).
Maintenance therapy with infliximab monotherapy is recommended for CD patients with infliximab in combination with immunosuppressants (weak recommendation, very low-quality evidence).
For CD patients with adalimumab in combination with immunosuppressants for long-term remission, continued maintenance therapy with adalimumab monotherapy is recommended (weak recommendation, low-quality evidence).
There is insufficient evidence to recommend that CD patients continue or discontinue anti-TNF therapy after obtaining long-term remission. It is recommended to individualize the decision on whether to continue anti-TNF therapy and always discuss the potential risks and benefits with the patient.
Part III: Perianal Fistula
Infliximab is recommended for induction and maintenance of remission in CD patients with complicated fistula (highly recommended, low-quality evidence).
Adalimumab is recommended for induction and maintenance of remission in patients with CD with complex fistula (weak recommendation, very low-quality evidence).
In patients with CD and complicated fistula, there is insufficient evidence of TNF inhibitors in combination with immunosuppressants for fistula healing (weakly recommended, very low-quality evidence).
In patients with CD and complicated fistula, there is insufficient evidence for the use of ususulumab for the treatment of fistula healing (weak recommendation, medium-quality evidence).
In patients with CD and complicated fistula, there is insufficient evidence for the use of vedozumab for fistula healing (weak recommendation, low-quality evidence).
In patients with CD and complicated fistula, antibiotics alone to promote fistula closure are not recommended (weak recommendation, low-quality evidence).
Thiopurine (azathioprine, mercaptopurine) is not recommended for monotherapy in patients with CD for complex perianal fistulas (weak recommendation, very low-quality evidence).
bibliography:
ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment.Journal of Crohn's and Colitis, Volume 14, Issue 1, January 2020, Pages 4–22.
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Article from: Love at the Extended Inflammatory Bowel Disease Foundation