Key Points
2
➤ Crohn's disease (CD) is a chronic inflammatory bowel disease with
substantial morbidity when not adequately controlled.
• Historically, approximately 20% of patients with CD were hospitalized every year,
and the risk of surgery within 1 year of diagnosis was 24%, 36% by 5 years, and
47% by 10 years.
• In recent years, outcomes have improved, likely because of earlier diagnosis,
increasing use of biologics, escalation or alteration of therapy based on disease
severity, and endoscopic management of colorectal cancer.
➤ The International Organization for the Study of Inflammatory
Bowel Diseases characterizes severe disease as having a high
risk for adverse disease-related complications, including surgery,
hospitalization, and disability, based on a combination of structural
damage, inflammatory burden, and impact of quality of life.
• Contributors to severe disease include large or deep mucosal lesions on endoscopy
or imaging, presence of fistula and/or perianal abscess, presence of strictures,
prior intestinal resections, particularly of segments >40 cm, presence of a stoma,
extensive disease (ileal involvement >40 cm, or pancolitis), anemia, elevated
C-reactive protein, and low albumin.
• With respect to symptoms, patients with severe disease may have at least 10
loose stools per day, daily abdominal pain, presence of anorectal symptoms (eg,
anorectal pain, bowel urgency, incontinence, discharge, and tenesmus), systemic
corticosteroid use within the prior year, lack of symptomatic improvement
despite prior exposure to biologics and/or immunosuppressive agents, or
significant impact of the disease on activities of daily living.
➤ The Crohn's Disease Activity Index standardized disease assessment
score categorizes severity of disease as: remission <150, mild to
moderate as 150–220, moderate to severe as 220–450 and severe >450.
• For this guideline, moderate to severe disease was considered a Crohn's Disease
Activity Index score of 220 or higher.
➤ There are a number of different drug classes available for the
management of moderate to severe CD, including:
• Tumor necrosis factor (TNF)–a antagonists (ie, infliximab, adalimumab,
certolizumab pegol), anti-integrin agents (natalizumab, vedolizumab),
interleukin 12/23 antagonist (ustekinumab), immunomodulators (thiopurines,
methotrexate), and corticosteroids (prednisone, budesonide).
➤ In general, most drugs, with the exception of corticosteroids, that
are initiated for induction of remission are continued as maintenance
therapy.
