This protocol addresses patients with Crohn's disease presenting at moderate-to-severe activity who carry one or more features associated with a higher risk for progressive disease course.
Moderate–severe activity is characterised by prominent symptoms such as fever, significant weight loss, and abdominal pain or tenderness — including patients who have not responded to treatment for milder disease.
Higher-risk features for disease progression include:
Management centres on short-term oral corticosteroid induction of remission, followed by a steroid-sparing maintenance immunomodulator strategy. Specific metabolic pre-testing is required before certain immunomodulator options can be started. The complete agent selection, sequencing, and required assessments are in the full protocol.
Clinical improvement within 2–4 weeks and maximal improvement by 12–16 weeks; durable steroid-free clinical and endoscopic remission.
DOI: 10.14309/ajg.0000000000003465
Individuals are considered to have moderate–severe disease if they have not responded to treatment for mild–moderate disease or if they present with more prominent symptoms such as fever, significant weight loss, abdominal pain or tenderness, intermittent nausea or vomiting.
We recommend oral corticosteroids for short-term induction of remission in patients with moderately to severely active CD (strong recommendation, low level of evidence).
We suggest azathioprine and 6-mercaptopurine for maintenance of remission in patients with moderately to severely active CD who had induction of remission with corticosteroids (conditional recommendation, low level of evidence).
We suggest methotrexate for maintenance of remission in patients with moderately to severely active CD who had induction of remission with corticosteroids (conditional recommendation, moderate level of evidence).
We recommend TPMT testing before initial use of azathioprine or 6-mercaptopurine to treat patients with CD (strong recommendation, low level of evidence).
In general, clinical evidence of improvement should be evident within 2–4 weeks, and the maximal improvement should occur by 12–16 weeks.
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