Crohn's Therapy Decision Tree
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Objective: Provide direction regarding choice of therapy for patients with Crohn’s disease. |
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Patient population: Adult patients (>18years) with known diagnosis of Crohn’s disease. |
Highlight BoxTherapy decisions are based on anatomic location of disease, severity of disease, disease complications, extra-intestinal manifestations of the disease, other comorbidities, and patient preference. Treatment goals include induction and maintenance of remission.
New therapies are constantly being developed and should be considered. |
Introduction
Crohn’s disease (CD) is a chronic inflammatory condition that affects any portion of the gastrointestinal tract from the mouth to the anus and perianal region. Extra-intestinal manifestations and/or complications can occur. The most commonly affected parts of the GI tract are the terminal ileum and colon. Inflammation is typically segmental, asymmetrical and transmural. Most patients are diagnosed with an inflammatory phenotype at first presentation, but over time, complications such as strictures, fistulas or abscesses can develop in over half of patients. These complications often require surgery.
Types of Crohn's Disease
The Montreal classification is commonly used to classify the major phenotypic features of CD based on age at diagnosis, location of the disease and disease behaviour.
Prior to therapy decisions, the following assessments should be carried out and treatment goals discussed with the patient.
Goal of therapy: deep and prolonged remission with long-term goal of preventing complications and halting the progressive course of the disease. Deep remission is a combination of symptomatic and objective markers of remission.
Management of mild Crohn's disease
Mild disease defined as CDAI <220 or HBI ≤7. Following complete evaluation with endoscopy (ileocolonoscopy +/- upper endoscopy) and/or imaging (enterography, capsule endoscopy, and/or intestinal ultrasound), and lab tests, the choice of treatment will in part depend on the distribution of disease as well as disease activity.
Management of moderate to severe Crohn's disease
Other Resources
For IBD Providers
Inflammatory Bowel Disease: Drug Comparison chart
For Patients
Crohn’s and Colitis Canada: IBD journey webpage
UpToDate® - Patient education: Crohn’s disease (Beyond the Basics) (freely accessible) https://www.uptodate.com/contents/crohn-disease-beyond-the-basics?search=crohns%20disease&source=search_result&selectedTitle=1~20&usage_type=default&display_rank=1
References
Nguyen et al. Positioning Therapies in the Management of Crohn’s Disease. Clin Gastroenterol and Hepatol 2020; 18(6):1268-79 https://doi.org/10.1016/j.cgh.2019.10.035
Panaccione et al. Canadian Association of Gastroenterology Clinical Practice Guidelines for the Management of Luminal Crohn’s Disease. J Can Assoc Gastroenterol 2019; 2(3): e1-e34 https://doi.org/10.1093/jcag/gwz019
Lichtensein et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterology 2018; 113:481-517 https://doi.org/10.1038/ajg.2018.27
Sandborn W.J. Evaluation and Treatment: Clinical Decision Tool Gastroenterology 2014; 147:702-705 https://doi.org/10.1053/j.gastro.2014.07.022
Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD. Gastroenterology. 2021;160(5):1570-1583. https://doi.org/10.1053/j.gastro.2020.12.031
2024 ECCO guidelines (expected Jan 2024)
