New Guideline for Treatment of Crohn Disease

Guideline Watch |
January 2, 2014

New Guideline for Treatment of Crohn Disease

  1. Douglas K. Rex, MD

The AGA has issued recommendations on use of immunomodulators and anti–TNF-α agents for induction and maintenance of remission in moderate-to-severe Crohn disease.

  1. Douglas K. Rex, MD

Sponsoring Organization: American Gastroenterological Association (AGA) Institute

Target Population: Gastroenterologists

Background and Objective

Recent evidence from randomized, controlled trials has refined our understanding of the best use of immunomodulators (thiopurines and methotrexate) and anti–tumor necrosis factor (TNF)–α agents in moderate-to-severe Crohn disease. The AGA has synthesized these findings into a new guideline, divided into recommendations for induction of remission and maintenance of remission.


For induction of remission:

  • Thiopurines and methotrexate are no longer recommended as primary therapies. Instead, patients can be treated with steroids or anti–TNF-α agents as primary therapy.

  • When treating patients with steroids, consider the addition of an immunomodulator (thiopurine or methotrexate) to maintain remission and obtain a corticosteroid-sparing effect.

  • When treating patients with anti–TNF-α agents, consider use of a thiopurine also.

For maintenance of remission:

  • If steroids were used for induction, then use an immunomodulator or an anti–TNF-α agent with or without a thiopurine.

  • If an anti–TNF-α agent was used for induction, then use an anti–TNF-α agent with or without a thiopurine.


Regarding the recommendation of adding a thiopurine to an anti–tumor necrosis factor–α agent for induction, the main issue is whether the addition of the thiopurine is worth risking potentially worse adverse effects, including lymphoma and particularly the devastating hepatosplenic T-cell lymphoma in young males. Clinicians should not attempt to induce remission in moderate-to-severe Crohn disease with an immunomodulator (thiopurine or methotrexate) alone. In the maintenance setting, the decision to add a thiopurine to an anti–TNF-α agent often involves issues such as the potential of thiopurines to reduce the development of antibodies in the case of infliximab and the increased risk for lymphoma.

This guideline reduces a complex body of literature to a clinically usable form. It is also accompanied by an excellent technical review of the literature on thiopurines, methotrexate, and anti–TNF-α biologic drugs as well as a useful figure demonstrating treatment recommendations in an algorithm.

Editor Disclosures at Time of Publication

  • Disclosures for Douglas K. Rex, MD at time of publication Consultant / Advisory board Exact Sciences; Ferring Pharmaceuticals; Given Imaging; Olympus Speaker’s bureau Boston Scientific; Braintree; Ferring Pharmaceuticals Grant / research support Battelle; Braintree; Northwestern University; Olympus America Editorial boards Annals of Gastroenterology and Hepatology; Comparative Effectiveness Research; Expert Review of Gastroenterology and Hepatology; Gastroenterology; Gastroenterology and Hepatology News; Gastroenterology Report; Gastroenterology Research and Practice; Journal of Clinical Gastroenterology; Techniques in Gastrointestinal Endoscopy; World Journal of Gastroenterology; World Journal of Gastrointestinal Oncology; World Journal of Gastrointestinal Pathophysiology; World Journal of Gastrointestinal Pharmacology and Therapeutics


Reader Comments (1)

Olga hano Physician, Gastroenterology, Instituto de Gastroenterología

I treat many case with Crohn´s disease and use for induction of remission, an immunomodulator (azathioprina) because in Cuba, anti–TNF-α biologic drugsare very expensive. Most of the patients respond well to this treatment.

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