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Luminal and Fistulizing Crohn’s Disease - Moderate-Severe

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9 Adult outpatients with moderate to severe luminal Crohn's disease Suggest using biologic agents (with or without immunomodulators) EARLY, rather than delaying their use until after failure of 5-aminosalicylate and/or corticosteroids (conditional, low) Thiopurines and methotrexate Corticosteroids and 5-aminosalicylate • Suggest corticosteroids over no treatment for induction of remission (conditional, moderate) • Recommend AGAINST the use of corticosteroids over no treatment for maintenance of remission (strong, moderate) • Recommend AGAINST the use of 5-aminosalicylate or sulfasalazine for induction or maintenance of remission (strong, moderate) • Suggest AGAINST the use of thiopurine monotherapy over no treatment for achieving remission (conditional, very low) • Suggest thiopurine monotherapy or intramuscular methotrexate monotherapy over no treatment for induction and maintenance of remission (conditional, moderate) • Suggest subcutaneous or intramuscular methotrexate monotherapy over no treatment for induction and maintenance of remission (conditional, moderate) • Suggest AGAINST the use of oral methotrexate monotherapy over no treatment for induction or maintenance of remission (conditional, very low) • Recommend biologic monotherapy over thiopurine monotherapy for induction of remission (strong, moderate) • In those naïve to biologics and immunomodulators, suggest infliximab or adalimumab in combination with thiopurine for induction and maintenance of remission over infliximab or adalimumab montherapy (conditional, moderate quality for infliximab and very low quality for adalimumab) Comment: Based on indirect evidence combination infliximab or adalimumab with mexotrexate may be more effective than infliximab or adalimumab monotherapy. • No recommendation regarding the use of ustekinumab or vedolizumab in combination with a thiopurine or methotrexate over biologic drug monotherapy (no recommendation, knowledge gap) • In quiescent CD on combination therapy, no recommendation for withdrawal of either immunomodulator or biologic over ongoing combination therapy of a biologic and an immunomodulator (no recommendation, knowledge gap)

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