Management of Crohn's disease: a summary of recommendations from NICE

  • NICE

  • curated by Pavankumar Kamat
  • Clinical Guidance Summaries
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Guideline name: Crohn’s disease: management [NG129]

Update type: New guideline

Published: May 2019

Takeaway

  • NICE has issued a guideline focusing on the management of Crohn's disease (CD) in children, young people and adults with the aim of reducing the symptoms and maintaining or improving the quality of life of patients.
  • The recommendations in this summarised version of the guideline do not cover the surgical management of CD.

Inducing remission

Monotherapy

  • Consider monotherapy with a conventional glucocorticosteroid to induce remission in individuals with an initial presentation or a single inflammatory exacerbation of CD during a 12-month period.
  • Enteral nutrition is preferred over conventional glucocorticosteroid for children and young people in whom there is concern about growth or side effects.
  • Consider budesonide for an initial presentation or a single inflammatory exacerbation in a 12-month period:
    • If the patient has ≥1 of distal ileal, ileocaecal or right-sided colonic disease and
    • If conventional glucocorticosteroids are contraindicated or not tolerated.
  • Aminosalicylate may be considered as an alternative to budesonide; however, it is less effective.
  • Budesonide or aminosalicylate are not recommended for severe presentations or exacerbations.
  • Monotherapy with azathioprine, mercaptopurine or methotrexate is recommended for inducing remission

Maintaining remission

  • Discuss the options for managing CD with the patients and their families or carers when the condition is in remission, including both treatment and no treatment.
  • If patients opt for no treatment:
    • Ensure that they are aware of the symptoms suggestive of a relapse and that they promptly consult their healthcare professional.
    • The importance of not smoking should be communicated to the patients.
  • If patients opt for treatment:
    • Offer azathioprine or mercaptopurine as monotherapy if previously used along with a glucocorticosteroid or budesonide to induce remission.
    • Consider azathioprine or mercaptopurine in individuals who haven't received them earlier for induction.
    • Consider methotrexate only if was earlier used to induce remission, or azathioprine or mercaptopurine for maintenance were not tolerated or are contraindicated
    • A conventional glucocorticosteroid or budesonide is not recommended.

Monitoring osteopenia and fracture risk

  • As CD is a cause of secondary osteoporosis, it is necessary to assess the risk for fragility fracture in adults.
  • Routine monitoring of bone mineral density in children and young people is not recommended, and is only justified if risk factors such as low BMI, low trauma fracture, long-term/recurrent glucocorticosteroid use are present.

Conception and pregnancy

  • Inform the patients regarding the risks and benefits of medical therapy and the possible effects of the condition on fertility.
  • Efficient communication and information-sharing are required across specialty teams involved in the care of pregnant women with CD.

This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP, FFCI, FRSA

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