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Medical Management of Crohn’s Disease

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The ASCRS Textbook of Colon and Rectal Surgery

Abstract

Despite tremendous progress in the overall understanding of the disease and advancements in the comprehension of the various phenotypical manifestations, the exact etiology of Crohn’s disease remains unknown. Many hypotheses suggest there involves interplay amongst the genetic makeup of the individual along with environmental, bacteriological, immunological, and epidemiological factors that contribute to its development. While surgery is often geared towards complications of the disease, medical therapy remains the mainstay of treatment. A tiered strategy for medical therapy is often utilized, taking into account the disease activity (flare vs. chronic), pattern (inflammatory vs. fistulizing vs. fibrotic), and location. Combined, the goal is to safely resolve inflammation, lessen symptoms, improve quality of life, and minimize the risk for short- and long-term complications. This chapter focuses specifically on the medical management of Crohn’s disease with a focus on not only the classification of commonly used medications, but also the various strategies implemented to induce and maintain remission.

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References

  1. Gasche C, Scholmerich J, Brynskov J, D’Haens G, Hanauer SB, Irvine EJ, Jewell DP, Rachmilewitz D, Sachar DB, Sandborn WJ, Sutherland LR. A simple classification of Crohn’s disease: report of the Working Party for the World Congresses of Gastroenterology, Vienna 1998. Inflamm Bowel Dis. 2000;6:8–15.

    CAS  PubMed  Google Scholar 

  2. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR, Caprilli R, Colombel JF, Gasche C, Geboes K, Jewell DP, Karban A, Loftus Jr EV, Peña AS, Riddell RH, Sachar DB, Schreiber S, Steinhart AH, Targan SR, Vermeire S, Warren BF. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005;19(Suppl A):5–36.

    Google Scholar 

  3. Satsangi J, Silverberg MS, Vermeire S, Colombel J-F. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006;55(6):749–53.

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Fedorak RN. Is it time to re-classify Crohn’s disease? Best Pract Res Clin Gastroenterol. 2004;18 Suppl:99–106.

    PubMed  Google Scholar 

  5. Louis E, Collard A, Oger AF, Degroote E, Aboul Nasr El Yafi FA, Belaiche J. Behaviour of Crohn’s disease according to the Vienna classification: changing pattern over the course of the disease. Gut. 2001;49:777–82.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. Freeman HJ. Application of the Vienna Classification for Crohn’s disease to a single clinician database of 877 patients. Can J Gastroenterol. 2001;15:89–93.

    CAS  PubMed  Google Scholar 

  7. Papi C, Festa V, Fagnani C, Stazi A, Antonelli G, Moretti A, Koch M, Capurso L. Evolution of clinical behaviour in Crohn’s disease: predictive factors of penetrating complications. Dig Liver Dis. 2005;37:247–53.

    CAS  PubMed  Google Scholar 

  8. Lovasz BD, Lakatos L, Horvath A, Szita I, Pandur T, Mandel M, Vegh Z, Golovics PA, Mester G, Balogh M, Molnar C, Komaromi E, Kiss LS, Lakatos PL. Evolution of disease phenotype in adult and pediatric onset Crohn’s disease in a population-based cohort. World J Gastroenterol. 2013;19:2217–26.

    PubMed  PubMed Central  Google Scholar 

  9. Krishnaprasad K, Andrews JM, Lawrance IC, Florin T, Gearry RB, Leong RW, Mahy G, Bampton P, Prosser R, Leach P, Chitti L, Cock C, Grafton R, Croft AR, Cooke S, Doecke JD, Radford-Smith GL. Inter-observer agreement for Crohn’s disease sub-phenotypes using the Montreal Classification: how good are we? A multi-centre Australasian study. J Crohns Colitis. 2012;6:287–93.

    PubMed  Google Scholar 

  10. Spekhorst LM, Visschedijk MC, Alberts R, Festen EA, van der Wouden EJ, Dijkstra G, Weersma RK, Dutch Initiative on Crohn and Colitis. Performance of the Montreal classification for inflammatory bowel diseases. World J Gastroenterol. 2014;20:15374–81.

    PubMed  PubMed Central  Google Scholar 

  11. Leiman DA, Lichtenstein GR. Therapy of inflammatory bowel disease: what to expect in the next decade. Curr Opin Gastroenterol. 2014;30:385–90.

    CAS  PubMed  Google Scholar 

  12. Best WR, Becktel JM, Singleton JW, Kern Jr F. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology. 1976;70:439–44.

    CAS  PubMed  Google Scholar 

  13. Sandler RS, Jordan MC, Kupper LL. Development of a Crohn’s index for survey research. J Clin Epidemiol. 1988;41:451–8.

    CAS  PubMed  Google Scholar 

  14. Thia K, Faubion Jr WA, Loftus Jr EV, Persson T, Persson A, Sandborn WJ. Short CDAI: development and validation of a shortened and simplified Crohn’s disease activity index. Inflamm Bowel Dis. 2011;17:105–11.

    PubMed  Google Scholar 

  15. Harvey RF, Bradshaw JM. A simple index of Crohn’s-disease activity. Lancet. 1980;1:514.

    CAS  PubMed  Google Scholar 

  16. Vermeire S, Schreiber S, Sandborn WJ, Dubois C, Rutgeerts P. Correlation between the Crohn’s disease activity and Harvey-Bradshaw indices in assessing Crohn’s disease severity. Clin Gastroenterol Hepatol. 2010;8:357–63.

    PubMed  Google Scholar 

  17. Mary JY, Modigliani R. Development and validation of an endoscopic index of the severity for Crohn’s disease: a prospective multicentre study. Groupe d’Etudes Thérapeutiques des Affections Inflammatoires du Tube Digestif (GETAID). Gut. 1989;30:983–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  18. Khanna R, Bouguen G, Feagan BG, D’Haens G, Sandborn WJ, Dubcenco E, Baker KA, Levesque BG. A systematic review of measurement of endoscopic disease activity and mucosal healing in Crohn’s disease: recommendations for clinical trial design. Inflamm Bowel Dis. 2014;20:1850–61.

    PubMed  Google Scholar 

  19. Mary JY, Modigliani R. Development and validation of an endoscopic index of the severity for Crohn’s disease: a prospective multicentre study. Groupe d’Etudes Thérapeutiques des Affections Inflammatoires du Tube Digestif (GETAID). Gut. 1989;30(7):983–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Daperno M, D’Haens G, Van Assche G, Baert F, Bulois P, Maunoury V, Sostegni R, Rocca R, Pera A, Gevers A, Mary JY, Colombel JF, Rutgeerts P. Development and validation of a new, simplified endoscopic activity score for Crohn’s disease: the SES-CD. Gastrointest Endosc. 2004;60:505–12.

    PubMed  Google Scholar 

  21. Cellier C, Sahmoud T, Froguel E, Adenis A, Belaiche J, Bretagne JF, Florent C, Bouvry M, Mary JY, Modigliani R. Correlations between clinical activity, endoscopic severity, and biological parameters in colonic or ileocolonic Crohn’s disease. A prospective multicentre study of 121 cases. The Groupe d’Etudes Thérapeutiques des Affections Inflammatoires Digestives. Gut. 1994;35:231–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. Schoepfer AM, Beglinger C, Straumann A, Trummler M, Vavricka SR, Bruegger LE, Seibold F. Fecal calprotectin correlates more closely with the Simple Endoscopic Score for Crohn’s disease (SES-CD) than CRP, blood leukocytes, and the CDAI. Am J Gastroenterol. 2010;105:162–9.

    CAS  PubMed  Google Scholar 

  23. Levesque BG, Sandborn WJ, Ruel J, Feagan BG, Sands BE, Colombel JF. Converging goals of treatment of inflammatory bowel disease from clinical trials and practice. Gastroenterology. 2015;148:37–51.

    Google Scholar 

  24. Byrne CM, Solomon MJ, Young JM, Selby W, Harrison JD. Patient preferences between surgical and medical treatment in Crohn’s disease. Dis Colon Rectum. 2007;50:586–97.

    PubMed  Google Scholar 

  25. Rolfe VE, Fortun PJ, Hawkey CJ, Bath-Hextall F. Probiotics for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev. 2006;(4):CD004826.

    Google Scholar 

  26. Butterworth AD, Thomas AG, Akobeng AK. Probiotics for induction of remission in Crohn’s disease. Cochrane Database Syst Rev. 2008;(3):CD006634.

    Google Scholar 

  27. Jonkers D, Penders J, Masclee A, Pierik M. Probiotics in the management of inflammatory bowel disease: a systematic review of intervention studies in adult patients. Drugs. 2012;72:803–23.

    PubMed  Google Scholar 

  28. Kale-Pradhan PB, Zhao JJ, Palmer JR, Wilhelm SM. The role of antimicrobials in Crohn’s disease. Expert Rev Gastroenterol Hepatol. 2013;7:281–8.

    CAS  PubMed  Google Scholar 

  29. Scribano ML, Prantera C. Use of antibiotics in the treatment of Crohn’s disease. World J Gastroenterol. 2013;19:648–53.

    PubMed  PubMed Central  Google Scholar 

  30. Feller M, Huwiler K, Schoepfer A, Shang A, Furrer H, Egger M. Long-term antibiotic treatment for Crohn’s disease: systematic review and meta-analysis of placebo-controlled trials. Clin Infect Dis. 2010;50:473–80.

    CAS  PubMed  Google Scholar 

  31. Khan KJ, Ullman TA, Ford AC, Abreu MT, Abadir A, Marshall JK, Talley NJ, Moayyedi P. Antibiotic therapy in inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. 2011;106:661–73.

    CAS  PubMed  Google Scholar 

  32. 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;104:465–83.

    PubMed  Google Scholar 

  33. Cheifetz AS. Management of active Crohn disease. JAMA. 2013;309:2150–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  34. Ford AC, Kane SV, Khan KJ, Achkar JP, Talley NJ, Marshall JK, Moayyedi P. Efficacy of 5-aminosalicylates in Crohn’s disease: systematic review and meta-analysis. Am J Gastroenterol. 2011;106:617–29.

    CAS  PubMed  Google Scholar 

  35. Criscuoli V, Modesto I, Orlando A, Cottone M. Mesalazine for the treatment of inflammatory bowel disease. Expert Opin Pharmacother. 2013;14:1669–78.

    CAS  PubMed  Google Scholar 

  36. Munkholm P, Langholz E, Davidsen M, Binder V. Frequency of glucocorticoid resistance and dependency in Crohn’s disease. Gut. 1994;35:360–2.

    CAS  PubMed  PubMed Central  Google Scholar 

  37. Faubion Jr WA, Loftus Jr EV, Harmsen WS, Zinsmeister AR, Sandborn WJ. The natural history of corticosteroid therapy for inflammatory bowel disease: a population-based study. Gastroenterology. 2001;121:255–60.

    CAS  PubMed  Google Scholar 

  38. Franchimont DP, Louis E, Croes F, Belaiche J. Clinical pattern of corticosteroid dependent Crohn’s disease. Eur J Gastroenterol Hepatol. 1998;10:821–5.

    CAS  PubMed  Google Scholar 

  39. Ford AC, Bernstein CN, Khan KJ, Abreu MT, Marshall JK, Talley NJ, Moayyedi P. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. 2011;106:590–9.

    CAS  PubMed  Google Scholar 

  40. Kuenzig ME, Rezaie A, Seow CH, Otley AR, Steinhart AH, Griffiths AM, Kaplan GG, Benchimol EI. Budesonide for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev. 2014;(8):CD002913.

    Google Scholar 

  41. Beaugerie L, Brousse N, Bouvier AM, Colombel JF, Lémann M, Cosnes J, Hébuterne X, Cortot A, Bouhnik Y, Gendre JP, Simon T, Maynadié M, Hermine O, Faivre J, Carrat F, CESAME Study Group. Lymphoproliferative disorders in patients receiving thiopurines for inflammatory bowel disease: a prospective observational cohort study. Lancet. 2009;374:1617–25.

    CAS  PubMed  Google Scholar 

  42. Chaparro M, Ordás I, Cabré E, Garcia-Sanchez V, Bastida G, Peñalva M, Gomollón F, García-Planella E, Merino O, Gutiérrez A, Esteve M, Márquez L, Garcia-Sepulcre M, Hinojosa J, Vera I, Muñoz F, Mendoza JL, Cabriada JL, Montoro MA, Barreiro-de Acosta M, Ceña G, Saro C, Aldeguer X, Barrio J, Maté J, Gisbert JP. Safety of thiopurine therapy in inflammatory bowel disease: long-term follow-up study of 3931 patients. Inflamm Bowel Dis. 2013;19:1404–10.

    PubMed  Google Scholar 

  43. Dassopoulos T, Sultan S, Falck-Ytter YT, Inadomi JM, Hanauer SB. American Gastroenterological Association Institute technical review on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn’s disease. Gastroenterology. 2013;145:1464–78.

    PubMed  Google Scholar 

  44. Khan KJ, Dubinsky MC, Ford AC, Ullman TA, Talley NJ, Moayyedi P. Efficacy of immunosuppressive therapy for inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. 2011;106:630–42.

    CAS  PubMed  Google Scholar 

  45. Lichtenstein GR, Feagan BG, Cohen RD, Salzberg BA, Diamond RH, Price S, Langholff W, Londhe A, Sandborn WJ. Serious infection and mortality in patients with Crohn’s disease: more than 5 years of follow-up in the TREAT™ registry. Am J Gastroenterol. 2012;107:1409–22.

    CAS  PubMed  PubMed Central  Google Scholar 

  46. McDonald JW, Tsoulis DJ, Macdonald JK, Feagan BG.Methotrexate for induction of remission in refractory Crohn’s disease. Cochrane Database Syst Rev. 2012;12:CD003459.

    Google Scholar 

  47. Patel V, Wang Y, MacDonald JK, McDonald JW, Chande N. Methotrexate for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev. 2014;(8):CD006884.

    Google Scholar 

  48. Singh S, Garg SK, Pardi DS, Wang Z, Murad MH, Loftus Jr EV. Comparative efficacy of biologic therapy in biologic-naïve patients with Crohn disease: a systematic review and network meta-analysis. Mayo Clin Proc. 2014;89:1621–35.

    PubMed  Google Scholar 

  49. Dignass A, Van Assche G, Lindsay JO, Lémann M, Söderholm J, Colombel JF, Danese S, D’Hoore A, Gassull M, Gomollón F, Hommes DW, Michetti P, O’Morain C, Oresland T, Windsor A, Stange EF, Travis SP, European Crohn’s and Colitis Organisation (ECCO). The second European evidence-based Consensus on the diagnosis and management of Crohn’s disease: current management. J Crohns Colitis. 2010;4:28–62.

    CAS  PubMed  Google Scholar 

  50. Orlando A, Armuzzi A, Papi C, Annese V, Ardizzone S, Biancone L, Bortoli A, Castiglione F, D’Incà R, Gionchetti P, Kohn A, Poggioli G, Rizzello F, Vecchi M, Cottone M, Italian Society of Gastroenterology; Italian Group for the study of Inflammatory Bowel Disease. The Italian Society of Gastroenterology (SIGE) and the Italian Group for the study of Inflammatory Bowel Disease (IG-IBD) Clinical Practice Guidelines: the use of tumor necrosis factor-alpha antagonist therapy in inflammatory bowel disease. Dig Liver Dis. 2011;43:1–20.

    PubMed  Google Scholar 

  51. Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T, Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology. Evidence-based clinical practice guidelines for Crohn’s disease, integrated with formal consensus of experts in Japan. J Gastroenterol. 2013;48:31–72.

    PubMed  Google Scholar 

  52. Terdiman JP, Gruss CB, Heidelbaugh JJ, Sultan S, Falck-Ytter YT, AGA Institute Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn’s disease. Gastroenterology. 2013;145:1459–63.

    PubMed  Google Scholar 

  53. Hazlewood GS, Rezaie A, Borman M, Panaccione R, Ghosh S, Seow CH, Kuenzig E, Tomlinson G, Siegel CA, Melmed GY, Kaplan GG. Comparative effectiveness of immunosuppressants and biologics for inducing and maintaining remission in Crohn’s disease: a network meta-analysis. Gastroenterology. 2015;148:344–54.

    Google Scholar 

  54. Pariente B, Laharie D. Review article: why, when and how to de-escalate therapy in inflammatory bowel diseases. Aliment Pharmacol Ther. 2014;40:338–53.

    CAS  PubMed  Google Scholar 

  55. Frolkis AD, Dykeman J, Negrón ME, Debruyn J, Jette N, Fiest KM, Frolkis T, Barkema HW, Rioux KP, Panaccione R, Ghosh S, Wiebe S, Kaplan GG. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population based studies. Gastroenterology. 2013;145:996–1006.

    PubMed  Google Scholar 

  56. Buisson A, Chevaux JB, Allen PB, Bommelaer G, Peyrin-Biroulet L. Review article: the natural history of postoperative Crohn’s disease recurrence. Aliment Pharmacol Ther. 2012;35:625–33.

    CAS  PubMed  Google Scholar 

  57. Singh S, Garg SK, Pardi DS, Wang Z, Murad MH, Loftus Jr EV. Comparative efficacy of pharmacologic interventions in preventing relapse of Crohn’s disease after surgery: a systematic review and network meta-analysis. Gastroenterology. 2015;148:64–76.

    Google Scholar 

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Authors and Affiliations

  1. Division of GI and Oncologic Surgery, Northwestern Medicine, 676 North Saint Clair St, Suite 650, Chicago, IL, 60611, USA

    Scott A. Strong MD, FACS, FASCRS

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  1. Scott A. Strong MD, FACS, FASCRS
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Correspondence to Scott A. Strong MD, FACS, FASCRS .

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Editors and Affiliations

  1. Division of Colorectal Surgery, University Hospitals Case Medical Center Case Western Reserve University, Cleveland, OH, USA

    Scott R. Steele

  2. Cleveland Clinic, Cleveland, OH, USA

    Tracy L. Hull

  3. Tufts University School of Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA

    Thomas E. Read

  4. Ambrose and Gladys Bowyer, Loyola University, Chicago, IL, USA

    Theodore J. Saclarides

  5. University of Texas Medical Branch at Galveston, Galveston, TX, USA

    Anthony J. Senagore

  6. Ochsner Medical Center, New Orleans, LA, USA

    Charles B. Whitlow

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© 2016 ASCRS (American Society of Colon and Rectal Surgeons)

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Strong, S.A. (2016). Medical Management of Crohn’s Disease. In: Steele, S.R., Hull, T.L., Read, T.E., Saclarides, T.J., Senagore, A.J., Whitlow, C.B. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-25970-3_47

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  • DOI: https://doi.org/10.1007/978-3-319-25970-3_47

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