Crohn's disease: Management in adults, children and young people
This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg152
Crohn's disease is a chronic inflammatory disease that mainly affects the gastrointestinal tract. There are currently at least 115,000 people in the UK with Crohn's disease. The causes of Crohn's disease are widely debated. Smoking and genetic predisposition are two important factors that are likely to play a role.
Typically people with Crohn's disease have recurrent attacks, with acute exacerbations interspersed with periods of remission or less active disease. Whether a relapse refers to a recurrence of symptoms or the appearance of mucosal abnormalities before the development of symptoms, remains the subject of dispute. Treatment is largely directed at symptom relief rather than cure, and active treatment of acute disease (inducing remission) should be distinguished from preventing relapse (maintaining remission).
Management options for Crohn's disease include drug therapy, attention to nutrition, smoking cessation and, in severe or chronic active disease, surgery.
The aims of drug treatment are to reduce symptoms and maintain or improve quality of life, while minimising toxicity related to drugs over both the short- and long-term. Glucocorticosteroid treatment, 5-aminosalicylate (5-ASA) treatment, antibiotics, immunosuppressives and tumour necrosis factor (TNF) alfa inhibitors are currently considered to be options for treating Crohn's disease. Enteral nutrition has also been used widely as first-line therapy in children and young people to facilitate growth and development, but its use in adults is less common. Between 50 and 80% of people with Crohn's disease will eventually need surgery for strictures causing symptoms of obstruction, other complications such as fistula formation, perforation or failure of medical therapy.
Up to a third of patients with Crohn's disease are diagnosed before the age of 21 but there is a lack of studies on treatment for children and young people. Paediatric practice is often based on extrapolation from adult studies and in this guideline all recommendations relate to adults, children and young people unless otherwise specified. Inducing and maintaining remission as well as optimising nutritional status and growth, and minimising psychological concerns and possible side effects of treatment are fundamental to best practice for all people with Crohn's disease, whatever their age.
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients. Because the guidance covers children, but the summaries of product characteristics for many drugs do not include children, the guideline will assume that prescribers will consult the current online version of the British national formulary for children.
This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the GMC's Good practice in prescribing medicines – guidance for doctors for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.