Editing Crohn's disease (section)

=== '''Medical management (based on eTG 2/1/23)''' ===

* Induction
** Mild-mod: Prednisolone/prednisone 40-50mg daily in the morning until clinical response, taper over 6-8 weeks. For ileocaecal disease, consider an enteric-coated preparation of budesonide (Entocort or Budenofalk), particularly for patients with a history of adverse reactions to systemic steroids, or precautions to their use (diabetes) - 9mg PO daily in the morning for 4-8 weeks, then taper over 2-4 weeks in 3mg increments to stop.
*** Antibiotics only if there is a confirmed infection
*** After 3 months, if no response, consider TNF inhibitor eg infliximab
** Severe: hydrocort 100mg q6h IV or methylprednisolone 60mg IV total daily, in single or divided dose
*** Generally give IV for 3-7 days depending on response. Switch to PO corticosteroids when disease activity has subsided.
*** Antibiotics only if confirmed infection
*** Alternatives/refractory disease: biologics - infliximab/updacitinib
* Maintenance
** Most patients need ongoing maintenance therapy
** Biologics can maintain remission if they were successfully used for induction
** Thiopurine therapy: azathioprine 2-2.5mg/kg PO daily OR mercaptopurine 1-1.5mg/kg PO daily
** Methotraxate 10-25mg subcut or IM, once per week OR 10-25mg PO weekly PLUS folic acid 5-10mg PO weekly on a different day
** Luminal or fistulising CD that is refractory to above therapy should be given a biologic
* Perianal Crohns disease:
** Metronidazole 400mg BD OR ciprofloxacin 500mg BD is appropriate for active perianal CD. Therapy may be needed for weeks to months. 
** Complex perianal disease should have a TNF inhibitor
* Ileal malabsorption (bile salt diarrhoea)
** Cholestyramine 2-4g PO daily, with all other drugs taken at least 1 hour prior or 4-6 hours afterwards
** Need B12, iron and fat-soluble vitamin supplementation