Guideline recommends multiple drug classes to treat adults with moderate to severe luminal, fistulizing Crohn's disease

A new American Gastroenterological Association guideline addressed the outpatient medical management of moderate to severe luminal and fistulizing Crohn's disease in adults, including which treatments to use for treatment and remission.

The clinical practice guideline is intended for primary care physicians and gastroenterologists, among other clinicians, and was published by Gastroenterology on June 1. Current evidence supports use of multiple drug classes, including tumor necrosis factor (TNF)-alpha antagonists, anti-integrins, anti-interleukin 12/23 inhibitors, methotrexate (subcutaneous/intramuscular), and corticosteroids for induction of remission, the guideline said. To maintain remission, TNF-alpha antagonists, anti-integrins, anti-interleukin 12/23 inhibitors, thiopurines, and methotrexate (subcutaneous/intramuscular) can be used, according to the guideline. “In general, most drugs, with the exception of corticosteroids, that are initiated for induction of remission are continued as maintenance therapy,” it stated.

Thiopurines and methotrexate were suggested for use as combination therapies with TNF-alpha antagonists for induction and maintenance of remission compared with TNF-alpha antagonist monotherapy.

The guideline made no recommendation on combination therapy with other biologics, given a lack of data. It also did not choose between withdrawal of either immunomodulators or a biologic agent over ongoing combination therapy in quiescent Crohn's disease. The guideline recommended against natalizumab, given its adverse effect profile and the availability of other medications to manage patients with moderate to severe Crohn's disease.

The guideline recommended against the use of thiopurines for induction of remission, corticosteroids for maintenance of remission, and 5-aminosalicylates for induction or maintenance of remission due to overall lack of efficacy. Finally, it suggested the early introduction of a biologic with or without an immunomodulator, rather than delaying use until after nonresponse to 5-aminosalicylates and/or corticosteroids.

In patients who were initially treated with a TNF-alpha antagonist and didn't respond, the guideline recommended the use of ustekinumab and suggested the use of vedolizumab. For patients who previously responded to infliximab (secondary nonresponse), the guideline recommended adalimumab or ustekinumab and suggested the use of vedolizumab.