Maintenance therapy in Crohn's disease

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Maintenance treatment for those who choose this option (1)

• azathioprine or mercaptopurine
  • should be offered as monotherapy to maintain remission when previously used with a conventional glucocorticosteroid or budesonide to induce remission
    • azathioprine or mercaptopurine should be considered 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)
      
      
• only consider methotrexate to maintain remission 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)

(Parenteral methotrexate is recommended for the maintenance of remission in patients with corticosteroid-dependent Crohn's). (2)

• do not offer a conventional glucocorticosteroid or budesonide to maintain remission. Systemic corticosteroids are not effective in maintaining remission and can cause unwanted adverse effects such as acne, round face, body hair growth, insomnia, weight gain, and osteoporosis. (3) Budesonide is not effective for maintenance of remission beyond 3 months following induction of remission. (4)

Patients who achieve remission with TNF-alpha inhibitors, vedolizumab, or ustekinumab should continue the same drug for maintenance of remission. (5)

Maintaining remission in Crohn's disease after surgery

• to maintain remission in people with ileocolonic Crohn's disease who have had complete macroscopic resection within the last 3 months, consider azathioprine in combination with up to 3 months' postoperative metronidazole
• consider azathioprine alone for people who cannot tolerate metronidazole
• do not offer biologics to maintain remission after complete macroscopic resection of ileocolonic Crohn's disease
• for people who have had surgery and started taking biologics before this guideline was published (May 2019), continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change
• do not offer budesonide to maintain remission in people with ileocolonic Crohn's disease who have had complete macroscopic resection

Notes:

• 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

Reference:

1. NICE. Crohn’s disease: management. NICE guideline NG129. Published May 2019
2. Torres J, Bonovas S, Doherty G, et al. ECCO guidelines on therapeutics in Crohn's disease: medical treatment. J Crohns Colitis. 2020 Jan 1;14(1):4-22.
3. Feuerstein JD, Ho EY, Shmidt E, et al. AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease. Gastroenterology. 2021 Jun;160(7):2496-508.
4. Kuenzig ME, Rezaie A, Seow CH, et al. Budesonide for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev. 2014 Aug 21;(8):CD002913.
5. Davies SC, Nguyen TM, Parker CE, et al. Anti-IL-12/23p40 antibodies for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev. 2019 Dec 12;(12):CD012804.