Remission induced by biologic agents in patients with moderately severe Crohn's disease

The anti-TNF-α biologic agents, such as infliximab or adalimumab, are recommended to induce remission in patients with moderately severe Crohn's disease, according to a new guideline from the American Gastroenterological Association (AGA). Additionally, the guidelines recommend against using thiopurines or methotrexate alone to induce remission in these patients. The new guideline1 and accompanying technical review2 have been published in Gastroenterology, the official journal of the AGA Institute. The AGA Clinical Decision Support Tool, based on the guideline, can be reviewed here.

"Crohn's disease is a lifelong, relapsing disorder that can damage the bowel and lead to multiple abdominal operations over time. Deciding which medications are the best is a common dilemma for gastroenterologists and the Crohn's patients we treat. The disease can be disabling, but the drugs to control the disease can be toxic too and they can be costly. Balancing the benefits and the risks of the drugs and determining which medicines are most likely to keep the patient healthy is critical," according to Jonathan P. Terdiman, MD, lead author of the guidelines, and Chief of the Gastroenterology Service at the University of California, San Francisco Medical Center. "The new AGA guideline and clinical decision support tool will ease the decision process by providing transparent and actionable recommendations."

Crohn's disease is a chronic inflammatory bowel disease that causes significant morbidity and represents a considerable burden to society. It is estimated that 300,000 to 500,000 Americans suffer from Crohn's disease, costing the health-care system between $2.5 and $4 billion per year.

These guidelines are the first to make medication recommendations based on methodology that includes review of risks and benefits, patient preferences, and the quality of clinical evidence.

For the induction of remission, the guidelines recommend:

• Using anti-TNF-α drugs to induce remission in patients with moderately severe Crohn's disease (strong recommendation, moderate-quality evidence).
• Using anti-TNF-α monotherapy over thiopurine monotherapy to induce remission in patients who have moderately severe Crohn's disease (strong recommendation, moderate-quality evidence).
• Using anti-TNF-α drugs in combination with thiopurines over thiopurine monotherapy to induce remission in patients who have moderately severe Crohn's disease (strong recommendation, high-quality evidence).

For maintenance of remission, the guidelines recommend:

• Using thiopurines over no immunomodulator therapy to maintain a steroid-induced remission in patients with Crohn's disease (strong recommendation, moderate-quality evidence).
• Using anti-TNF-α drugs over no anti-TNF-α drugs to maintain a steroid or anti-TNF-α drug-induced remission in patients with Crohn's disease (strong recommendation, high-quality evidence).