›Corticosteroids for maintenance — not recommended
›Greater than 2 courses per year indicates need for therapy escalation
Corticosteroids — severe and inpatient disease
›IV methylprednisolone — severe or fulminant inpatient disease
›40 to 60 mg IV once daily
›Class I recommendation — expert consensus
›Assess response at 72 hours
›If no response at 72 hours — rescue therapy required
›Hydrocortisone IV alternative
›300 to 400 mg per day in divided doses
›Equivalent to approximately 60 to 75 mg methylprednisolone daily
›Corticosteroid adverse effects monitoring
›Hyperglycemia — glucose monitoring every 6 to 8 hours
›Infection risk — maintain VTE prophylaxis
›Bone protection — calcium 1000 to 1500 mg and vitamin D 800 to 1000 IU daily
Biologic therapy — rescue and escalation
›Infliximab — steroid-refractory or fulminant disease
›5 mg/kg IV infusion at weeks 0, 2, 6 then every 8 weeks maintenance
›Higher weight-based dosing preferred in high inflammatory burden
›Combination with azathioprine or methotrexate improves durability
›Early biologic initiation — 79% steroid-free remission at 1 year vs 15% with step-up approach
›Contraindications to infliximab
›Active infection — must treat before initiating
›Untreated latent TB — complete latent TB treatment first
›Active hepatitis B — antiviral prophylaxis required
›Class III or IV heart failure — avoid
›Adalimumab — moderate to severe disease or maintenance
›Induction 160 mg SC week 0, 80 mg week 2
›Maintenance 40 mg SC every 2 weeks
›Dose escalation to 40 mg weekly if loss of response
›Alternative biologics for biologic-experienced patients
›Risankizumab — IL-23 inhibitor, moderate-certainty evidence support
›600 mg IV induction at weeks 0, 4, 8
›Maintenance 360 mg SC every 8 weeks
›Ustekinumab — IL-12/23 inhibitor
›Weight-based IV induction: 260 to 520 mg single dose
›Maintenance 90 mg SC every 8 weeks
›Vedolizumab — gut-selective anti-integrin
›300 mg IV at weeks 0, 2, 6 then every 8 weeks
›Favored when infection risk is major concern — gut-selective mechanism
›Upadacitinib — JAK1 inhibitor — moderate to severe active Crohn's disease
›Induction 45 mg PO once daily for 12 weeks
›Maintenance 15 mg or 30 mg PO once daily
›Screen for latent TB, malignancy risk, cardiovascular risk before initiating
›Contraindicated in active serious infections
›Adverse effect monitoring
›CBC — lymphopenia and anemia
›Lipid panel — JAK inhibitors increase LDL
›VTE risk — inform patient and monitor
Immunomodulators — maintenance and combination
›Azathioprine
›1.5 to 2.5 mg/kg PO daily
›Check TPMT or NUDT15 genotype before initiation — poor metabolizers at risk for myelosuppression
›Monitor CBC and LFTs every 3 months
›Not effective as monotherapy for acute flare — onset 3 to 6 months
›6-Mercaptopurine
›0.75 to 1.5 mg/kg PO daily
›Same monitoring as azathioprine
›Used when azathioprine not tolerated
›Methotrexate — alternative immunomodulator
›15 to 25 mg SC or IM weekly for induction
›Maintenance 15 mg weekly
›Folate supplementation 1 mg daily to reduce toxicity
›Contraindicated in pregnancy — teratogenic
Antibiotics — perianal and septic complications
›Antibiotics for perianal disease and abscess
›Metronidazole
›400 to 500 mg PO three times daily for perianal disease
›Not recommended for luminal disease maintenance
›Peripheral neuropathy risk with prolonged use
›Ciprofloxacin
›500 mg PO twice daily — often combined with metronidazole
›QT prolongation risk — avoid with concurrent QT-prolonging medications
›IV antibiotics for septic complications
›Piperacillin-tazobactam
›4.5 g IV every 6 hours
›Broad gram-negative and anaerobic coverage for intra-abdominal infection
›Ceftriaxone plus metronidazole alternative
›Ceftriaxone 2 g IV daily
›Metronidazole 500 mg IV every 8 hours
Surgical and procedural management
›Surgical indications
›Perforation
›Uncontrolled hemorrhage
›Obstruction not responding to medical therapy
›Failure of medical rescue therapy in fulminant disease
›Abscess requiring drainage
›Percutaneous drainage — abscess greater than or equal to 3 cm
›CT-guided or ultrasound-guided percutaneous drainage
›IV antibiotics concurrently
›Reassess for surgery vs medical therapy after drainage
›Perianal disease management
›Surgical drainage of perianal abscess
›Seton placement for complex fistula
›Combined medical and surgical approach — infliximab plus surgical drainage superior to either alone