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Medical Management of Pediatric Luminal Crohn’s Disease: CAG Guideline


Medical Management of Pediatric Luminal Crohn’s Disease: CAG Guideline

Canadian Association of Gastroenterology has released Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn’s Disease which aims to provide guidance for medical treatment of luminal Crohn’s disease in children. The guideline developers performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn’s disease. The consensus includes 25 statements focused on medical treatment options.The guidelines have been published in the Journal of the Canadian Association of Gastroenterology.

Key Recommendations are –

  • In patients with moderate Crohn’s disease, we recommend against the use of 5-aminosalicylates to induce clinical remission.
  • In patients with moderate Crohn’s disease limited to the colon, we suggest against the use of sulfasalazine to induce clinical remission.
  • In patients with Crohn’s disease in clinical remission, we recommend against sulfasalazine or 5-aminosalicylic acid to maintain clinical remission.
  • In patients with mild to moderate ileal and/or right colonic Crohn’s disease, we suggest oral controlled ileal release budesonide to induce clinical remission.
  • In patients with Crohn’s disease, we recommend against oral controlled ileal release budesonide to maintain clinical remission.
  • In patients with moderate to severe Crohn’s disease, we suggest conventional corticosteroids (eg, prednisone) to induce clinical remission.
  • In patients with mild to moderately active Crohn’s disease despite the use of sulfasalazine, 5-aminosalicylate, oral budesonide, or exclusive enteral nutrition, we suggest oral prednisone to induce clinical remission.
  • In patients with Crohn’s disease of any severity, we recommend against oral corticosteroids to maintain clinical remission.
  • In patients with Crohn’s disease, we suggest exclusive enteral nutrition to induce clinical remission.
  • In patients with Crohn’s disease, we recommend against partial enteral nutrition to induce clinical remission.
  • In patients with Crohn’s disease in remission, we suggest that if partial enteral nutrition is used it should be combined with other medications to maintain clinical remission.
  • In patients with Crohn’s disease of any severity, we recommend against thiopurine monotherapy to induce clinical remission.
  • In female patients with Crohn’s disease, we suggest a thiopurine to maintain remission.
  •  In patients with Crohn’s disease, we suggest that testing for thiopurine methyltransferase by genotype or enzymatic activity be done prior to initiating thiopurine therapy to guide dosing.
  •  In patients with Crohn’s disease, we suggest parenteral methotrexate to maintain clinical remission.
  • In patients with Crohn’s disease who are in clinical remission with a thiopurine or methotrexate as maintenance therapy, we suggest assessment for mucosal healing within the first year to determine the need to modify therapy if significant ulcerations persist.
  • In patients with moderate to severe inflammatory Crohn’s disease who have failed to achieve clinical remission with corticosteroids, we recommend anti-TNF therapy (adalimumab, infliximab) to induce and maintain clinical remission.
  • In patients with moderate to severe inflammatory Crohn’s disease who fail to achieve or maintain clinical remission with a thiopurine or methotrexate, we recommend anti-TNF therapy to induce and maintain clinical remission.
  • In patients with severe inflammatory Crohn’s disease judged at risk for progressive, disabling disease, we suggest anti-TNF therapy as first-line therapy to induce and maintain clinical remission.
  • When starting infliximab in males, we suggest against using it in combination with a thiopurine.
  • When starting adalimumab in males, we suggest against using it in combination with a thiopurine.
  • In male patients with Crohn’s disease receiving immunomodulatory therapy in combination with anti-TNF therapy, we suggest methotrexate in preference to thiopurines.
  • In patients with Crohn’s disease who have a suboptimal clinical response to anti-TNF induction therapy or loss of response to maintenance therapy, we suggest regimen intensification informed by therapeutic drug monitoring.
  • In patients with moderate to severe Crohn’s disease who fail to achieve or maintain clinical remission with anti–TNF-based therapy, we suggest ustekinumab to induce and maintain clinical remission.
  • In patients with Crohn’s disease, we recommend against cannabis or derivatives to induce or maintain remission.

For more details click on the link: doi: 10.1093/jcag/gwz018

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