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Early use of biologics recommended for moderate-to-severe Crohn's disease

Thu, 05/27/2021 - 16:14
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The American Gastroenterological Association has released new clinical guidelines outlining the benefits and risks of each drug currently available to Crohn's patients. Based on this research, AGA recommends the early introduction of biologics for patients experiencing luminal and fistulising Crohn's disease rather than waiting until other treatments fail. These guidelines, ‘AGA Clinical Practice Guideline on the Medical Management of Moderate to Severe Luminal and Fistulizing Crohn's Disease’, were published in Gastroenterology.

Biologics are the most effective drugs for the management of Crohn's and they should be used early, rather than delaying their use until after failure of mesalamine and/or corticosteroids, in patients with moderate to severe or fistulising Crohn's disease. These drugs are antibodies and can more precisely target the immune system which is causing the inflammation in Crohn's disease.

Key guideline recommendations included:

  • Anti-tumor necrosis factor (anti-TNF) agents or ustekinumab are recommended and vedolizumab is suggested as a first-line treatment.
  • In patients who have previously not responded to anti-TNF agents, AGA recommends ustekinumab or vedolizumab.
  • The biologic natalizumab is no longer recommended due to potential adverse events and the availability of safer treatment options.
  • In adult outpatients with moderate to severe CD who are naïve to biologic drugs, the AGA recommends the use of infliximab, adalimumab, or ustekinumab, over certolizumab pegol for the induction of remission (Strong recommendation, moderate certainty evidence) and suggests the use of vedolizumab over certolizumab pegol for the induction of remission.
  • In adult outpatients with moderate to severe CD who never responded to anti-TNFα (primary nonresponse), the AGA recommends the use of ustekinumab (Strong recommendation, moderate certainty evidence) and suggests the use of vedolizumab over no treatment for the induction of remission.
  • In adult outpatients with moderate to severe CD who previously responded to infliximab (secondary nonresponse), the AGA recommends the use of adalimumab or ustekinumab (Strong recommendation, moderate certainty evidence) and suggests the use of vedolizumab over no treatment for the induction of remission.
  • In adult outpatients with moderate to severe CD, the AGA suggests against the use of thiopurines monotherapy over no treatment for achieving remission.
  • In adult outpatients with quiescent moderate to severe CD (or patients in corticosteroid-induced remission), the AGA suggests the use of thiopurines monotherapy over no treatment for the maintenance of remission.
  • In adult outpatients with moderate to severe CD, the AGA suggests the use of subcutaneous or intramuscular methotrexate monotherapy over no treatment for the induction and maintenance of remission.
  • In adult outpatients with moderate to severe CD, the AGA suggests against the use of oral methotrexate monotherapy over no treatment for the induction and maintenance of remission.
  • In adult outpatients with moderate to severe CD, the AGA recommends the use of biologic drug monotherapy over thiopurine monotherapy for the induction of remission.

"With many new drugs entering the market, clinician's ability to treat patients with Crohn's disease has improved greatly over the last 20 years," said lead author, Dr Joseph D Feuerstein, from Beth Israel Deaconess, Boston, MA. "We hope this new guideline serves as a manual for clinicians in selecting the right therapies for their patients, which should lead to improved patient outcomes and less need for invasive surgery."

To access these guidelines, please click here