AGA Institute Care Pathway for the Identification,
Assessment and Initial Medical Treatment in Crohn's Disease
Figure 6
Perform treatment for patient in remission
Low-risk patient
F
Mod/high-risk patient
d
H
Options:
• Stop therapy and observe
(high chance of relapse
over 1 year)
• Budesonide 6 mg/day
(median time to relapse
prolonged by approximately
114 days, but no difference
in remission rates versus
placebo at 1 year)*
• Immunosuppressive
therapy (AZA, 6MP and
MTX have been shown to
be effective for maintaining
steroid-induced remissions
with prednisone or
prednisolone, but are
associated with rare risk of
infection and lymphoma)
* Consider bone mineral density
monitoring
Steroid induced
remission
Options:
• Use immunomodulator
(thiopurine or
MTX) over no
immunomodulator
• Use anti-TNF +/-
thiopurine over no
anti-TNF
Anti-TNF or anti-TNF
+ thiopurine induced
remission
• Use anti-TNF +/-
thiopurine over no
anti-TNF
Remains in remission
for 6 months
Does not remain in
remission for 6 months
Define resolution
of inflammation
and ulcers
Re-assess
inflammatory
markers every
3 months
d
Combination therapy with immunosuppressant
and anti-TNF biologic offers improved efficacy and
durability compared with anti-TNF monotherapy
and should be considered for mod/high-risk patients
requiring 2
nd
or 3
rd
biologic.
