Crohn’s Disease

Deep, transmural inflammation affecting any part of the GI tract

Ileum and colon most commonly affected
Damage to bowel wall can cause:
 Structures (narrowing of the bowel)
 Fistulas (abnormal connections or opening in the bowel)

Symptoms: Chronic diarrhea (nocturnal), abdominal pain, and weight loss

Fissures, and bleeding can be present before bowel symptoms

CD and UC Comparison
Clinical Features Crohn’s Disease Ulcerative Colitis
Diarrhea Bloody or non-bloody Bloody
Fistulas/Strictures Common Uncommon
Location Entire GI tract (especially ileum Colon (especially the rectum)
and colon)
Depth Transmural Superficial
Pattern Non-continuous “cobblestone” Continuous
appearance
Smoking Risk factor Protective

Diagnosis
IBD difficult to diagnose because the symptoms mimic other common conditions
Colonoscopy with tissue biopsy **Gold Standard**
Lab blood tests (inflammatory markers such as CRP) and stool testing (fecal calprotectin test)
 Can potentially be helpful

Lifestyle and Non-Pharmacologic Mangement

Avoid food triggers
 Smaller, more frequent meals
 Low in fat and dairy
 Drink plenty of water; Avoid caffeine and alcohol or carbonated beverages
Avoid medications with sorbitol or lactose
 Excipients used to hold tablets together

Drug Treatment
Induction of remission (treat exacerbations or active disease) and/or maintenance of remission

Maintenance of Remission
Mild Disease of ileum and/or right colon
Moderate-Severe Disease
(monotherapy or in combination)
Oral Budesonide
 ≤ 3 months
 Discontinue after course or switch to
thiopurine or methotrexate
Anti-TNF Agents
 Adalimumab (Humira)
 Infliximab (Remicade)
 Certolizumab (Cimzia)
Thiopurine (Azathioprine, Mercaptopurine)
Methotrexate
IL receptor Antagonist
 Ustekinumab (Stelara)
 Maintenance of Remission
Refractory Integrin Receptor Antagonists
Inadequate response  Vedolizumab
Cannot tolerate conventional therapies  Natalizumab

Steroids (Induction)
Drug Dosing Safety/Side Effects/Monitoring
Prednisone 5-60 mg daily CI: Systemic fungal infections, live
Tablet, DR tablet, oral solution vaccines

Budesonide (Entocort EC) Induction: 9 mg PO QAM for up to
ER capsule 8 weeks
Maintenance: 6 mg PO daily for 3
months, then taper
Side Effects
Short-term: ↑ appetite/weight, GI
upset, ↑ BP and glucose
Long-term: adrenal suppression,
immunosuppression, osteoporosis
Taper if used > 2 weeks
Long-term use: assess bone density,
consider bisphosphonates if needed

Budesonide: Extensive first-pass

metabolism

Thiopurines (Induction + Maintenance)

Drug Dosing Safety/Side Effects/Monitoring
Azathrioprine 1.5-3 mg/kg/day IV or PO BBW: Chronic immunosuppression
Tablet, injection ↑ risk of malignancy; Risk for
CrCl 10-50: 75% of normal dose hematologic toxicities (Pts with
CrCl < 10: 50% of normal dose genetic deficiency of thiopurine
methyltransferase (TPMT) are at ↑
risk of myelosuppresion

Side Effects: N/V/D, ↑ LFTs

Consider TPMT genetic testing

Dose reduce when used in combo

w/ allopurinol (allopurinol inhibits
pathway of inactivation)

Take after meals or divide doses to

↓ GI effects
Mercaptopurine 1-1.5 mg/kg/day Same as azathioprine (w/ no BBW)
Tablet, oral suspension EXCEPT:
CrCl ≤ 50: Lowest rec. initial dose
Take on empty stomach

Methotrexate
Induction + maintenance remission in moderate-severe CD for patients who cannot tolerate azathioprine
Dosed once weekly IM or SC injection

Drug
Adalimumab (Humira)
Single dose pre-filled syringe/pen
Infliximab (Remicade)
Renflexis, Inflectra biosimilar
Injection
Certolizumab (Cimzia)
Single dose pre-filled syringe and vial
Integrin Receptor Antagonists (Induction + Maintenance)
Drug
Natalizumab (Tysabri)
Injection
Vedolizumab (Entyvio)
Injection
Anti-TNF Agents
Dosing
40 mg SC every other week
Can ↑ to 40 mg weekly if not taken
with MTX
3 mg/kg IV at weeks 0, 2, and 6,
then every 8 weeks
Can ↑ to 10 mg/kg or treat every 4
weeks based on need (will also ↑
risk of infection)
Requires filter; Stable only in NS
Delayed hypersensitivity reaction
3-12 days after administration
400 mg SC at weeks 0, 2, and 4,
then 200 mg SC every other week
Can consider 400 mg every 4
weeks
Dosing
300 mg IV over 1 hour q 4 weeks
D/C if no response by 12 weeks
300 mg IV over 30 min at 0, 2, and
6 weeks, then every 8 weeks
D/C if no benefit by week 14
Safety/Side Effects/Monitoring
BBW: Serious infections; Screen
for latent TB prior to therapy
CI: Doses > 5 mg/kg in mod-severe
heart failure (Infliximab)
Warnings: Can cause demyelinating
disease, HepB reactivation,
hepatotoxicity
Side Effects
Infections and injection site
reactions
Requires refrigeration (will
denature if hot); Adalimumab can
be at RT for a max of 14 days
Safety/Side Effects/Monitoring
BBW: Progressive multifocal
leukoencephalopathy (PML) -
Monitor for mental status change
Side Effects
Infusion reactions, HA, depression
Stable in NS only; Do not shake
If taking steroids when initiating:
Taper steroids when onset of
benefit is observed; Stop Tysabri if
steroids cannot be tapers within 6
months
BBW: PML
Side Effects
HA, arthralgia, nasopharyngitis
Monitor neurological symptoms,
routine TB screening
Refrigerate and store in original
packaging to protect from light