Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
Clin Gastroenterol Hepatol. 2019 Aug;17(9):1680-1713. doi: 10.1016/j.cgh.2019.02.043. Epub 2019 Mar 7.
BACKGROUND & AIMS: Crohn's disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD.
We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists.
The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent.
Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.
克罗恩病（CD）是一种终身疾病，发病率很高，尽管已经开发出了新的治疗方法和治疗模式。我们为轻度至重度活动性腔肠 CD 的非住院患者的治疗提供了指导。
我们进行了系统评价，以确定有关 CD 管理的已发表研究。根据推荐评估、制定和评估（GRADE）方法，对证据质量和建议强度进行了评级。通过迭代在线平台制定陈述，然后由一组专家进行最终确定和投票。
共识包括 41 条针对 6 种主要药物类别的陈述：抗生素、5-氨基水杨酸、皮质类固醇、免疫抑制剂、生物制剂和其他治疗方法。专家组建议不要将抗生素或 5-氨基水杨酸用于诱导或维持治疗。皮质类固醇治疗（包括布地奈德）可作为诱导治疗，但不能作为维持治疗。在免疫抑制剂中，硫嘌呤不应用于诱导治疗，但可用于选定低风险患者的维持治疗。建议对依赖皮质类固醇的 CD 患者使用肠外甲氨蝶呤进行诱导和维持治疗。生物制剂，包括肿瘤坏死因子拮抗剂、vedolizumab 和 ustekinumab，推荐用于常规诱导治疗失败的患者，并作为维持治疗。专家组无法明确界定在开始使用生物制剂时同时使用免疫抑制剂治疗的作用。
CD 的最佳治疗需要仔细评估患者，承认患者的偏好，基于证据使用现有治疗方法，并彻底评估以确定治疗成功。
