Treatment
8
* Given evidence of harm in post marketing data from progressive multifocal leukoencephalopathy
(PML) and the availability of other drugs, the AGA suggests against the use of natalizumab. Patients
who are John Cunningham ( JC) virus antibody negative who put a high value on the potential
benefits and lower value on PML risk and who will adhere to ongoing monitoring for JC virus
positivity, may consider using natalizumab.
Figure 1. Medical Management of Adult Outpatients with
Moderate to Severe Luminal Crohn's Disease
Biologic-naïve patients; first-line therapy
Never responded to anti-TNF-α
(primary non-response)
Previously responded to infliximab
(secondary non-response)
Biologic therapy
For induction and maintenance of remission:
• Recommend any of the following anti-TNF-α over no treatment:
infliximab, adalimumab, certolizumab pegol (strong, moderate for
infliximab and adalimumab and low for certolizumab pegol)
• Suggest vedolizumab over no treatment (conditional, low for induction,
moderate for maintenance)
• Recommend ustekinumab over no treatment (strong, moderate)
• Suggest AGAINST the use of natalizumab over no treatment
(conditional, moderate)*
• Recommend
ustekinumab over
no treatment for
induction of remission
(strong, moderate)
• Suggest vedolizumab
over no treatment for
induction of remission
(conditional, low)
• Recommend adalimumab or ustekinumab
over no treatment for induction of
remission (strong, moderate)
• Suggest vedolizumab over no treatment
for induction of remission (conditional, low)
Comment: If adalimumab was the first line
drug utilized there is indirect evidence to
suggest using infliximab as a second line
agent.
• Recommend infliximab, adalimumab or ustekinumab over
certolizumab pegol for induction of remission (strong, moderate)
• Suggest vedolizumab over certolizumab pegol for induction of
remission (conditional, low)
Moderate to severe luminal
Crohn's disease defined as:
• CDAI score of 220 or higher
• High risk of adverse disease-
related complications including
surgery, hospitalization,
and disability based on a
combination of structural
damage, inflammatory burden
and impact of quality of life
