Therapy for Crohn disease

Medical therapy for Crohn disease has advanced incrementally: Small, non-definitive controlled trials of mesalamine continue to be reported, but the results are not sufficient to change the conclusion of a large meta-analysis that shows only marginal benefit of mesalamine in Crohn disease. Low-dose, controlled ileal-release budesonide is not effective for preventing postoperative recurrence of Crohn disease. A loading dose of intravenous azathioprine does not accelerate the time to response in patients with steroid-treated Crohn disease; however, standard azathioprine may work more quickly than previously reported. Mycophenolate mofetil may be therapeutically equivalent to azathioprine for active Crohn disease. There is a trend toward benefit of oral methotrexate (15 mg/wk) for active Crohn disease, and there is no significant difference in the blood concentrations of methotrexate in patients with inflammatory bowel disease who receive methotrexate (15 or 25 mg weekly) administered subcutaneously. Results in a pilot study suggest that tacrolimus may close perianal fistulas in patients with Crohn disease. The anti-tumor necrosis factor antibody infliximab is effective in closing perianal and enterocutaneous fistulas and in maintaining remission in patients with Crohn disease. Infliximab also leads to endoscopic and histologic remission. There is a trend toward benefit of subcutaneous recombinant interleukin-11 for active Crohn disease. Two pilot studies have shown that thalidomide may be of benefit in patients with refractory Crohn disease.