Crohn’s disease: management

National Institute for Health and Care Excellence


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Patient information and support

  • Ensure that information and advice about Crohn’s disease:
    • is age appropriate 
    • is of the appropriate cognitive and literacy level, and
    • meets the cultural and linguistic needs of the local community
  • Discuss treatment options and monitoring with the person with Crohn’s disease, and/or their parent or carer if appropriate, and within the multidisciplinary team. Apply the principles outlined in patient experience in adult NHS services (NICE guideline CG138)
  • Discuss the possible nature, frequency and severity of side-effects of drug treatment with people with Crohn’s disease, and/or their parents or carers if appropriate 
  • Give all people with Crohn’s disease, and/or their parents or carers if appropriate, information, advice and support in line with published NICE guidance on:
    • smoking cessation
    • patient experience 
    • medicines adherence 
    • fertility
  • Give people with Crohn’s disease, and/or their parents or carers if appropriate, additional information on the following when appropriate:
    • possible delay of growth and puberty in children and young people
    • diet and nutrition
    • fertility and sexual relationships
    • prognosis
    • side-effects of their treatment
    • cancer risk
    • surgery
    • care of young people in transition between paediatric and adult services
    • contact details for support groups
  • Offer adults, children and young people, and/or their parents or carers, age‑appropriate multidisciplinary support to deal with any concerns about the disease and its treatment, including concerns about body image, living with a chronic illness, and attending school and higher education

Inducing remission in Crohn’s disease

Monotherapy

  • Offer monotherapy with a conventional glucocorticosteroid (prednisolone, methylprednisolone or intravenous hydrocortisone) to induce remission in people with a first presentation or a single inflammatory exacerbation of Crohn’s disease in a 12‑month period
  • Consider enteral nutrition as an alternative to a conventional glucocorticosteroid to induce remission for:
    • children in whom there is concern about growth or side-effects, and
    • young people in whom there is concern about growth
  • In people with one or more of distal ileal, ileocaecal or right‑sided colonic disease who decline, cannot tolerate or in whom a conventional glucocorticosteroid is contraindicated, consider budesonide* for a first presentation or a single inflammatory exacerbation in a 12‑month period. Explain that budesonide is less effective than a conventional glucocorticosteroid but may have fewer side-effects
  • In people who decline, cannot tolerate or in whom glucocorticosteroid treatment is contraindicated, consider 5‑aminosalicylate (5‑ASA) treatment for a first presentation or a single inflammatory exacerbation in a 12‑month period. Explain that 5‑ASA is less effective than a conventional glucocorticosteroid or budesonide but may have fewer side-effects than a conventional glucocorticosteroid
  • Do not offer budesonide or 5‑ASA treatment for severe presentations or exacerbations
  • Do not offer azathioprine, mercaptopurine or methotrexate as monotherapy to induce remission

Add‑on treatment

  • Consider adding azathioprine or mercaptopurine to a conventional glucocorticosteroid or budesonide* to induce remission of Crohn’s disease if:
    • there are two or more inflammatory exacerbations in a 12‑month period, or 
    • the glucocorticosteroid dose cannot be tapered
  • Assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine. Do not offer azathioprine or mercaptopurine if TPMT activity is deficient (very low or absent). Consider azathioprine or mercaptopurine at a lower dose if TPMT activity is below normal but not deficient (according to local laboratory reference values)
  • Consider adding methotrexate§,l to a conventional glucocorticosteroid or budesonide* to induce remission in people who cannot tolerate azathioprine or mercaptopurine, or in whom TPMT activity is deficient, if:
    • there are two or more inflammatory exacerbations in a 12‑month period, or 
    • the glucocorticosteroid dose cannot be tapered
  • Monitor the effects of azathioprine, mercaptopurine and methotrexate§,l as advised in the current online version of the British national formulary(BNF) or British national formulary for children(BNFC). Monitor for neutropenia in those taking azathioprine or mercaptopurine even if they have normal TPMT activity
  • Ensure that there are documented local safety monitoring policies and procedures (including audit) for adults, children and young people receiving treatment that needs monitoring. Nominate a member of staff to act on abnormal results and communicate with GPs and people with Crohn’s disease and/or their parents or carers, if appropriate

Maintaining remission in Crohn’s disease

  • Discuss with people with Crohn’s disease, and/or their parents or carers if appropriate, options for managing their disease when they are in remission, including both no treatment and treatment. The discussion should include the risk of inflammatory exacerbations (with and without drug treatment) and the potential side-effects of drug treatment. Record the person’s views in their notes
  • Offer colonoscopic surveillance in line with colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohn’s disease or adenomas (NICE guideline CG118)

Follow‑up during remission for those who choose not to receive maintenance treatment

  • When people choose not to receive maintenance treatment:
    • discuss and agree with them, and/or their parents or carers if appropriate, plans for follow‑up, including the frequency of follow‑up and who they should see
    • ensure they know which symptoms may suggest a relapse and should prompt a consultation with their healthcare professional (most frequently, unintended weight loss, abdominal pain, diarrhoea, general ill‑health)
    • ensure they know how to access the healthcare system if they experience a relapse 
    • discuss the importance of not smoking

Maintenance treatment for those who choose this option

  • Offer azathioprine or mercaptopurine as monotherapy to maintain remission when previously used with a conventional glucocorticosteroid or budesonide to induce remission
  • Consider azathioprine or mercaptopurine to maintain remission in people who have not previously received these drugs (particularly those with adverse prognostic factors such as early age of onset, perianal disease, glucocorticosteroid use at presentation and severe presentations)
  • Consider methotrexate§,l to maintain remission only in people who:
    • needed methotrexate to induce remission, or
    • have tried but did not tolerate azathioprine or mercaptopurine for maintenance or
    • have contraindications to azathioprine or mercaptopurine (for example, deficient TPMT activity or previous episodes of pancreatitis)
  • Do not offer a conventional glucocorticosteroid or budesonide to maintain remission
  • See above for guidance on monitoring the effects of azathioprine, mercaptopurine and methotrexate

Maintaining remission in Crohn’s disease after surgery

  • Consider azathioprine or mercaptopurine to maintain remission after surgery in people with adverse prognostic factors such as:
    • more than one resection, or
    • previously complicated or debilitating disease (for example, abscess, involvement of adjacent structures, fistulising or penetrating disease)
  • Consider 5‑ASA treatment to maintain remission after surgery

Monitoring for osteopenia and assessing fracture risk

  • Refer to the NICE guideline on osteoporosis: assessing the risk of fragility fracture (NICE guideline CG146) for recommendations on assessing the risk of fragility fracture in adults. Crohn’s disease is a cause of secondary osteoporosis
  • Do not routinely monitor for changes in bone mineral density in children and young people
  • Consider monitoring for changes in bone mineral density in children and young people with risk factors, such as low body mass index (BMI), low trauma fracture or continued or repeated glucocorticosteroid use

Conception and pregnancy

  • Give information about the possible effects of Crohn’s disease on pregnancy, including the potential risks and benefits of medical treatment and the possible effects of Crohn’s disease on fertility
  • Ensure effective communication and information‑sharing across specialties (for example, primary care, obstetrics and gastroenterology) in the care of pregnant women with Crohn’s disease

* Although use is common in UK clinical practice, at the time of publication (October 2012), budesonide did not have a UK marketing authorisation specifically for children and young people. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Licensing arrangements remained unchanged when the guideline was updated (May 2016)
† Although use is common in UK clinical practice, at the time of publication (October 2012) mesalazine, olsalazine and balsalazide did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Licensing arrangements remained unchanged when the guideline was updated (May 2016)
‡ Although use is common in UK clinical practice, at the time of publication (October 2012) azathioprine and mercaptopurine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Licensing arrangements remained unchanged when the guideline was updated (May 2016)
§ Although use is common in UK clinical practice, at the time of publication (October 2012) methotrexate did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Licensing arrangements remained unchanged when the guideline was updated (May 2016)
Follow BNF/BNFC cautions on prescribing methotrexate
¶ Advice on monitoring of immunosuppressives can be found in the BNF/BNFC. The gastroenterology chapter and other relevant sections should be consulted

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/cg152

National Institute for Health and Care Excellence. Crohn's disease: management. Updated May 2016.  
First included: Feb 13.


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