Crohn's disease: Management (NICE guidelines)

A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has no past medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day and drinks 20 units of alcohol per week. Ileocolonoscopy shows features consistent with Crohn's disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the most important intervention to reduce the chance of further episodes?
A. Infliximab
B. Stop drinking
C. Stop smoking
D. Mesalazine
E. Budesonide

Answer:
C. Stop smoking

Discussion:
Crohn's disease: Management:
Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.

NICE published guidelines on the management of Crohn's disease in 2012.

General points:

• patients should be strongly advised to stop smoking 
• some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy.

Inducing remission:

• Glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients 
• Enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) 
• 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective 
• Azathioprine or mercaptopurine may be used as an add-on medication to induce remission but is not used as monotherapy. 
• Methotrexate is an alternative to azathioprine 
• Infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate 
• Metronidazole is often used for isolated peri-anal disease 

Maintaining remission:

• As above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) 
• Azathioprine or mercaptopurine is used first-line to maintain remission 
• Methotrexate is used as second-line 
• 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery 

Surgery :

• Around 80% of patients with Crohn's disease will eventually have surgery