NICE issued separate guidelines on Crohn’s disease (NG129) and ulcerative colitis (NG130) in May 2019. Management of IBD looks at inducing and maintaining remission along with considerations around surgery. Several recommendations for drugs involve off-label usage.16,17
For inducing remission in Crohn’s disease, a glucocorticoid (prednisolone, methylprednisolone or intravenous hydrocortisone) should be considered for people with a first presentation or a single inflammatory exacerbation of Crohn’s disease in a 12€‘month period. Budesonide may be considered as an alternative. While it is less effective than a conventional glucocorticoid it may have fewer side effects.16
If glucocorticoids are contraindicated, consider an aminosalicylate (5-ASAs), although these may be less effective than steroids.
Add-on treatment options include budesonide (in children and young people), mercaptopurine, azathioprine or methotrexate. Choice depends on the frequency of exacerbations and the response to the glucocorticoid. Patients should be monitored for neutropenia.
NICE defines severe active Crohn's disease as “very poor general health and one or more symptoms such as weight loss, fever, severe abdominal pain and usually frequent (3 to 4 or more) diarrhoeal stools daily. People with severe active Crohn's disease may or may not develop new fistulae or have extra€‘intestinal manifestations of the disease”.
For severe Crohn’s disease, NICE recommends one of four monoclonal antibodies: infliximab, adalimumab, ustekinumab or vedolizumab, but within licensed indications or following the relevant NICE technology appraisal as appropriate.
Options for maintenance therapy in remission include monotherapy using azathioprine, mercaptopurine or methotrexate depending on patient acceptability and what drug had been used with a glucocorticoid or budesonide to induce remission.
To maintain remission if surgery has taken place, azathioprine alone or in combination with up to 3 months’ postoperative metronidazole can be considered, while monitoring for neutropenia. People who had been using biologics in these circumstances and prior to the introduction of the NICE guideline were advised to discuss whether it was appropriate to change to azathioprine.