Clinical Review

Medical management of Crohn’s disease

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39547.603218.AE (Published 08 May 2008) Cite this as: BMJ 2008;336:1062
  1. J R Fraser Cummings, specialist registrar,
  2. Satish Keshav, consultant gastroenterologist,
  3. Simon P L Travis, consultant gastroenterologist
  1. 1Gastroenterology Unit, John Radcliffe Hospital, Oxford OX3 9DU
  1. Correspondence to: S P L Travis simon.travis{at}ndm.ox.ac.uk

    Summary points

    • Biological therapies have radically changed the management of Crohn’s disease but must be used judiciously with great awareness of possible adverse events

    • Treatment strategies for the disease are rapidly evolving, with immunomodulator and biological therapy being considered in patients who have indicators for developing early severe disease

    • Clinical indicators of a poor prognosis (at diagnosis) include perianal or stricturing disease, weight loss >5 kg, or the need for steroids

    • Treatment of active disease with mesalazine is little better than placebo; mesalazine is used mainly to reduce the risk of relapse after small intestinal resection

    • Access to specialist services, parallel medical and surgical clinics, nurse specialists, dietitians, pharmacists, and other allied professionals is as important as the medication

    • Publication of standards of care should drive improvement in the care and provision of resources for patients with Crohn’s disease

    Crohn’s disease is a chronic, relapsing and remitting inflammatory condition of the gastrointestinal tract. Treatment has changed radically over the past decade with the introduction of biological therapy and increased use of immunomodulators. Awareness of the therapeutic potential and associated adverse events is necessary both for offering benefit and for protecting patients from undue risks from these treatments.

    How common is Crohn’s disease?

    The median population incidence of the disease is 6.7 (range 1.6 to 14.6) cases per 100 000 annually and prevalence is 140 (10-199) cases per 100 000 in the West.1 About 690 000 people in Europe, including about 90 000 people in the United Kingdom, have the disease, with estimated healthcare costs of €3.04bn (£2.4bn; $4.8bn) and £300m a year respectively.2

    How does Crohn’s disease present?

    The disease presents at any age, although usually at age 16-30 years; it has a disproportionate effect on economically active individuals. Common presenting symptoms include diarrhoea, abdominal pain, weight loss, and fatigue. The disease is characterised by transmural intestinal inflammation, with occasional extraintestinal features such as …

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