Diagnosis

• Give patients advice specifically on the following
  • Smoking cessation
  • Patient experience
  • Medicines adherence
  • Fertility
• Once in remission discuss options for disease management including risk of inflammatory exacerbations without treatment

Investigation

• Assess thiopurine methyltransferase (TPMT) activity before offering azathioprine, avoid if depressed
• Colonic surveillance in line with CG118
• Bone mineral density only if co-existing low BMI, low trauma fracture or repeated gluco-corticosteroid usage

Management

Inducing Remission

• Monotherapy in first presentation of single exacerbation in 12 mth period consisting of Gluco-corticoid steroid (prednisolone, hydro-prednisolone, IV hydrocortisone)
• Consider enteral nutrition as alternative to steroid if there is a growth concern
• In right sided (distal ileal, ileo-caecal) who cannot tolerate conventional steroid, offer Budesonide (unconventional steroid) or 5-Amino-salicylate (though 5-ASA less effective)
• Do not offer Azathioprine, Mercaptopurine OR Methotrexate as monotherapy to induce remission, instead offer Azathioprine Mercaptopurine OR Methotrexate in combination with a gluco-corticoid to induce remission if there are two of more exacerbations within 12 mths or if steroid cannot be tapered off
• Infliximab and adalimumab (TNF-alpha Ab) should be offered in severe crohns that have not responded to or intolerant of conventional therapy
• Severe crohns: weight loss, fever, severe abdo pain, 3-4 loose stools/day

Maintaining Remission

• Offer Azathioprine or Mercaptopurine as monotherapy to maintain remission, as well as adverse prognostic factors post-surgical resection
• Consider Methotrexate to maintain remission only if previous required to induce remission, or cannot tolerate Azathioprine or Mercaptopurine
• Consider 5-ASA treatment to maintain remission post surgery
• Do not offer gluco-corticoid steroids

Surgery

• Offer surgery if disease limited to the distal ileum, explore risks & benefits as well recurrence rates
• Consider early in course of disease in before or early puberty whose growth is restricted

Strictures

• Balloon dilatation if single short stricture
• Discuss benefits and risk of balloon dilatation and surgical resection with patient, surgeon, gastroenterologist

NICE Source: CG152 Crohn’s disease: management. Summary compiled by Dr D P Sheppard MBBS.