Overview of the medical management of severe or refractory Crohn disease in adults
- Richard J Farrell, MD
Richard J Farrell, MD
- Gastroenterology Consultant, Connolly Hospital
- Associate Clinical Professor, Royal College of Surgeons in Ireland
- Mark A Peppercorn, MD
Mark A Peppercorn, MD
- Professor of Medicine
- Harvard Medical School
Crohn disease is an inflammatory condition of unknown etiology that can affect any portion of the gastrointestinal tract from the mouth to the perianal area. Its transmural inflammatory nature coupled with the variability of organ distribution gives rise to a spectrum of clinical presentations, each of which has to be considered separately in deciding upon the proper therapeutic approach. (See "Clinical manifestations, diagnosis and prognosis of Crohn disease in adults".)
Clinical trials of Crohn disease often use formal grading systems to describe disease severity. Two commonly used systems are the Crohn's Disease Activity Index (CDAI) (calculator 1) and the Harvey-Bradshaw Index (HBI) (calculator 2) , which is a simplified derivative of the CDAI. The HBI has been shown to correlate with the CDAI . A drop in the CDAI of 100 points corresponds to a 3-point drop in the HBI. A CDAI of <150 (clinical remission) corresponds to an HBI of <4.
The following working definitions may be more practical for clinical practice :
●Asymptomatic remission (CDAI <150) – Patients who are asymptomatic either spontaneously or after medical or surgical intervention. Patients requiring steroids to remain asymptomatic are not considered to be in remission but are referred to as being "steroid-dependent."
●Mild to moderate Crohn disease (CDAI 150-220) – Ambulatory patients able to tolerate an oral diet without dehydration, toxicity, abdominal tenderness, mass, obstruction, or >10 percent weight loss.
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- SEVERE DISEASE
- REFRACTORY DISEASE
- Azathioprine and 6-mercaptopurine
- Biologic therapies
- - Anti-TNF therapies
- Adalimumab and certolizumab pegol
- Safety of anti-TNF therapies
- Switching or de-escalating biologic or immunomodulator therapies
- Failure of anti-TNF therapy
- - Anti-integrin antibodies
- - Anti-IL-12/23 antibody
- Continued disease resistance
- VENOUS THROMBOEMBOLISM
- MEDICAL MANAGEMENT OF CROHN DISEASE COMPLICATIONS
- Localized peritonitis
- Small bowel obstruction
- POSTOPERATIVE RECURRENCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS