Twelve principles to guide treatment of Crohn's disease

We have many new drugs to manage Crohn’s disease.

This is great for clinicians and patients alike.

But it can be overwhelming, and not all drugs are available to all patients across the world. Restrictions apply: cost, guidelines, approvals, insurance providers to name just a few.

Follow this set of simple principles to guide care whatever the therapy.

---

1/ Crohn's disease is progressive

With long-term, irreversible bowel damage, disability and poor quality of life the result.

---

2/ Diagnostic delay is associated with worse outcomes

Ensure effective systems are in place to mitigate against this.

Systematic review with meta-analysis: Time to diagnosis and the impact of delayed diagnosis on clinical outcomes in inflammatory bowel disease

---

3/ Disease complications can be prevented with effective therapy

This may involve over-treating a few patients to avoid under-treatment the majority.

---

4/ Starting effective therapy early results in best outcomes

Effective therapy means an advanced therapy -

• anti-TNF or

• anti-p40 or

• anti-p19 or

• anti-integrin or

• a JAK inhibitor and

• combination therapy (in the future)

  

---

5/ There is a disconnect between symptoms and inflammation

Use non-invasive monitoring tools like faecal calprotectin and intestinal ultrasound.

---

6/ Biosimilar anti-TNFs are the most cost effective drugs

They work, are accessible, and allow for rapid dose escalation.

This might be

• infliximab plus azathioprine or

• adalimumab (plus or minus azathioprine) and

• ustekinumab (available across Europe July 2024)

---

7/ Early ileo-caecal resection should be offered to patients

And it offers excellent long-term outcomes for many.

This should be offered to all newly diagnosed patients with limited terminal ileal disease.

Ensure good systems in place to monitor for recurrence with prophylactic therapy in at risk patients.

---

8/ 5-ASA compounds do not work effectively in Crohn's disease

They only work at the mucosal level and Crohn's is a transmural disease.

Do not use 5-ASA in Crohn’s disease.

---

9/ Steroids do not heal the mucosa in Crohn's disease

Do not (over)use them.

---

10/ Dietary therapy is important in Crohn's disease

Use exclusive enteral nutrition in place of steroids for small bowel disease.

It works in adults as well as kids.

Use low residue diet for stricturing disease.

Mediterranean diet for everyone else.

---

11/ The psychological harm associated with Crohn's disease is high

It starts early in the disease course and includes suicidal ideation and completed suicide.

Do not underestimate this.

Association Between IBD and Psychiatric Morbidity and Suicide: A Swedish Nationwide Population-Based Cohort Study With Sibling Comparisons

---

12/ Work as a multi-disciplinary team

And put the patient at the centre of that team.

The cornerstone of any good IBD team are IBD specialist nurses.

Other members of an effective IBD MDT:

• surgeons

• dieticians

• radiologists

• pathologists

• pharmacists

• psychologists

• research team

• administrative team

• rheumatologists, dermatologists and ophthalmologists

With your team focus on patient centered care and try to think holistically.

---