Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Related articles

Overview of the medical management of severe or refractory Crohn's disease in adults

INTRODUCTION

Crohn's 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's disease in adults".)

Clinical trials of Crohn's 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) [1], which is a simplified derivative of the CDAI. The HBI has been shown to correlate with the CDAI [2]. 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 [3]:

  • 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's disease (CDAI 150-220) – Ambulatory patients able to tolerate an oral diet without dehydration, toxicity, abdominal tenderness, mass, obstruction, or >10 percent weight loss.
  • Moderate to severe Crohn's disease (CDAI 220-450) – Patients who have failed treatment for mild to moderate disease or patients with prominent symptoms such as fever, weight loss, abdominal pain and tenderness, intermittent nausea or vomiting, or anemia.
  • Severe-fulminant disease (CDAI >450) – Patients with persisting symptoms despite conventional glucocorticoids or biologic agents (infliximab, adalimumab, certolizumab pegol, or natalizumab) as outpatients, or individuals presenting with high fevers, persistent vomiting, intestinal obstruction, significant peritoneal signs, cachexia, or evidence of an abscess.

This topic will provide an overview of the use of immunomodulators and biologic therapies for severe or refractory Crohn's disease. It will also review the options for medical management of patients with fistulae, peritonitis, abscesses, and small bowel obstructions. The approach to patients with mild to moderate Crohn's disease, detailed discussions of individual medications, and other treatments for Crohn's disease are discussed separately:

                    

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2012. | This topic last updated: Sep 8, 2011.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2012 UpToDate, Inc.
References
Top
  1. Harvey RF, Bradshaw JM. A simple index of Crohn's-disease activity. Lancet 1980; 1:514.
  2. Vermeire S, Schreiber S, Sandborn WJ, et al. Correlation between the Crohn's disease activity and Harvey-Bradshaw indices in assessing Crohn's disease severity. Clin Gastroenterol Hepatol 2010; 8:357.
  3. Lichtenstein GR, Hanauer SB, Sandborn WJ, Practice Parameters Committee of American College of Gastroenterology. Management of Crohn's disease in adults. Am J Gastroenterol 2009; 104:465.
  4. Te HS, Schiano TD, Kuan SF, et al. Hepatic effects of long-term methotrexate use in the treatment of inflammatory bowel disease. Am J Gastroenterol 2000; 95:3150.
  5. Peyrin-Biroulet L, Deltenre P, de Suray N, et al. Efficacy and safety of tumor necrosis factor antagonists in Crohn's disease: meta-analysis of placebo-controlled trials. Clin Gastroenterol Hepatol 2008; 6:644.
  6. Ford AC, Sandborn WJ, Khan KJ, et al. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 2011; 106:644.
  7. Hanauer SB, Sandborn WJ, Rutgeerts P, et al. Human anti-tumor necrosis factor monoclonal antibody (adalimumab) in Crohn's disease: the CLASSIC-I trial. Gastroenterology 2006; 130:323.
  8. Sandborn WJ, Hanauer SB, Rutgeerts P, et al. Adalimumab for maintenance treatment of Crohn's disease: results of the CLASSIC II trial. Gut 2007; 56:1232.
  9. Colombel JF, Sandborn WJ, Rutgeerts P, et al. Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology 2007; 132:52.
  10. Schreiber S, Khaliq-Kareemi M, Lawrance IC, et al. Maintenance therapy with certolizumab pegol for Crohn's disease. N Engl J Med 2007; 357:239.
  11. Schreiber S, Rutgeerts P, Fedorak RN, et al. A randomized, placebo-controlled trial of certolizumab pegol (CDP870) for treatment of Crohn's disease. Gastroenterology 2005; 129:807.
  12. Malchow H, Ewe K, Brandes JW, et al. European Cooperative Crohn's Disease Study (ECCDS): results of drug treatment. Gastroenterology 1984; 86:249.
  13. Steinhart AH, Ewe K, Griffiths AM, et al. Corticosteroids for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2003; :CD000301.
  14. Akobeng AK, Thomas AG. Enteral nutrition for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2007; :CD005984.
  15. Ostro MJ, Greenberg GR, Jeejeebhoy KN. Total parenteral nutrition and complete bowel rest in the management of Crohn's disease. JPEN J Parenter Enteral Nutr 1985; 9:280.
  16. Kappelman MD, Horvath-Puho E, Sandler RS, et al. Thromboembolic risk among Danish children and adults with inflammatory bowel diseases: a population-based nationwide study. Gut 2011; 60:937.
  17. Miehsler W, Reinisch W, Valic E, et al. Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism? Gut 2004; 53:542.
  18. Nguyen GC, Sam J. Rising prevalence of venous thromboembolism and its impact on mortality among hospitalized inflammatory bowel disease patients. Am J Gastroenterol 2008; 103:2272.
  19. Carter MJ, Lobo AJ, Travis SP, IBD Section, British Society of Gastroenterology. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl 5:V1.
  20. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:381S.
  21. Korelitz BI, Present DH. Favorable effect of 6-mercaptopurine on fistulae of Crohn's disease. Dig Dis Sci 1985; 30:58.
  22. Agrawal A, Durrani S, Leiper K, et al. Effect of systemic corticosteroid therapy on risk for intra-abdominal or pelvic abscess in non-operated Crohn's disease. Clin Gastroenterol Hepatol 2005; 3:1215.
  23. Garcia JC, Persky SE, Bonis PA, Topazian M. Abscesses in Crohn's disease: outcome of medical versus surgical treatment. J Clin Gastroenterol 2001; 32:409.
  24. Gervais DA, Hahn PF, O'Neill MJ, Mueller PR. Percutaneous abscess drainage in Crohn disease: technical success and short- and long-term outcomes during 14 years. Radiology 2002; 222:645.