AGA publishes recommendations for treatment of moderate-to-severe luminal, fistulizing Crohn's
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The AGA published guidelines in Gastroenterology for the management of moderate-to-severe luminal and fistulizing Crohn’s disease.
“The goal of this guideline is to promote high-value, evidence-based care and to facilitate shared decision-making with patients in the management of moderate to severe luminal and fistulizing CD,” Joseph D. Feuerstein, MD, from the division of gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center in Boston, and colleagues wrote.
The guidelines address outpatient medical management of moderate to severe luminal and fistulizing CD; however, most recommendations may also apply to inpatients. The AGA used the Grading of Recommendations Assessment, Development and Evaluation while developing the guidelines.
Guidelines for adult outpatients with moderate-to-severe luminal and fistulizing Crohn’s disease include:
Anti-tumor necrosis factor over no treatment should be used for induction and maintenance of remission. Entyvio (vedolizumab, Takeda) over no treatment should be used for the induction and maintenance of remission. Stelara (ustekinumab, Janssen) over no treatment should be used for the induction and maintenance of remission.
Tysabri (natalizumab, Biogen) over no treatment is not advised for the induction and maintenance of remission.
In patients who are naive to biologic drugs, Remicade (infliximab, Janssen), Humira (adalimumab, AbbVie), or ustekinumab over certolizumab pegol should be used for the induction of remission and the use of vedolizumab over certolizumab pegol for the induction of remission.
In those who never responded to anti-TNF therapy, ustekinumab and vedolizumab should be used over no treatment for the induction of remission.
Among patients who previously responded to infliximab, adalimumab or ustekinumab and vedolizumab over no treatment should be used for the induction of remission.
The use of thiopurines over no treatment are not advised for achieving remission.
Among patients with quiescent moderate-to-severe CD or patients in corticosteroid-induced remission, thiopurines over no treatment should be used for the maintenance of remission.
The use of subcutaneous or intramuscular methotrexate monotherapy over no treatment is not advised for the induction and maintenance of remission.
The use of oral methotrexate monotherapy over no treatment is not advised for the induction and maintenance of remission.
Biologic drug monotherapy over thiopurine monotherapy should be used for the induction of remission.
Among those who are naive to biologics and immunomodulators, infliximab in combination with thiopurines should be used for the induction and maintenance of remission over infliximab monotherapy. Adalimumab in combination with thiopurines should be used for the induction and maintenance of remission over adalimumab monotherapy.
No recommendation was made for ustekinumab or vedolizumab combined with thiopurines or methotrexate over biologic drug monotherapy for the induction and maintenance of remission.
Among those with quiescent CD on combination therapy, no recommendation was made for withdrawal of either the immunomodulator or the biologic over ongoing combination therapy of a biologic and an immunomodulator.
Early introduction with a biologic with or without an immunomodulator is suggested rather than delaying their use until after failure of 5-aminosalicylates and/or corticosteroids.
Corticosteroids over no treatment should be used for induction of remission. Corticosteroids over no treatment for maintenance of remission are not advised.
Use of 5-aminosalicylates or sulfasalazine are not advised over no treatment for the induction or maintenance of remission.
Among those with CD and active perianal fistula, infliximab over no treatment should be used for the induction and maintenance of fistula remission. Also, adalimumab, ustekinumab, or vedolizumab over no treatment should be used.
Among those with CD and active perianal fistula without perianal abscess, the use of antibiotics alone is not advised over no treatment for the induction of fistula remission. However, use of biologic agents in combination with an antibiotic over a biologic drug alone is recommended.
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