Therapeutic approaches for Crohn's disease based on the S3 guidelines 

The treatment of chronic inflammatory bowel disease is difficult and depends on the individual patient. Severity of the disease from. Crohn's disease and Ulcerative colitis are two of the most widespread chronic inflammatory bowel diseases. The disease, Crohn's disease, can affect the entire gastrointestinal tract, i.e. it can begin in the area of the esophagus and extend to the anus. A distinction is made between patients in whom the upper part of the gastrointestinal tract is affected and those in whom the lower part of the digestive system is affected. The upper area includes the esophagus up to the upper part of the small intestine. In the lower area, the small and large intestines are primarily affected. Accordingly, the treatment approaches for Crohn's disease must be different from other chronic inflammatory bowel diseases (IBD).

The article deals with the different degrees of severity of the disease and how it can be treated. It focuses on the S3 guidelines for Crohn's disease supported. All information can be found there in more detail. 

As already established in 2015, the primary treatment goal for a diagnosis of Crohn's disease is the Mucosa healing. The inner intestinal mucosa is referred to as the mucosa. It appears in the form of protrusions. In Crohn's disease, the mucosa is damaged at various points in the gastrointestinal tract. In contrast to ulcerative colitis, it is not only the upper layers that are damaged, but also deeper layerssuch as the connective tissue or the muscle layer.

The image shows where the intestinal mucosa becomes inflamed in Crohn's disease. Image source: W&B/Jörg Neisel

The image shows where the inflammation in ulcerative colitis is located in the intestine. Image source: W&B/Jörg Neisel

Further goals of Crohn's disease therapy are to achieve a steroid-free remission and the associated improvement in patients' living conditions. In addition, targeted therapy is intended to reduce the need for Hospitalization or operations be reduced. Another objective is to achieve and maintain a Remission in Crohn's disease. Remission is the period of the disease during which there are few or no symptoms.

Crohn's disease occurs in various degrees of severity. A distinction is made between a mild to moderate flare-up, a moderate to severe flare-up and possible fistula formation. 

Which therapy is used for the individual patient depends on various factors. In addition to the infestation pattern, these include the presence of diseases, the in connection with the CED disease stand. However, diseases that have no connection with the IBD diagnosis are also taken into account. In addition, the Agethe Nutritional status and the associated Deficiencies important parameters that are taken into account when deciding on a particular form of therapy.

We will now briefly introduce you to the various therapies that can be used to treat Crohn's disease, depending on the severity of the flare-ups. However, always speak individual with your doctor to find out which Therapy for your disease progression comes into question. The overview of the forms of therapy none No claim to completeness.

According to the S3 guideline, the active ingredient mesalazine may be considered for mild flare-ups. However, depending on the individual clinical picture, it is also possible that no medication will be prescribed. 

Budesonide is also used for Crohn's disease. This is used for mild to moderate relapses. The inflammation is mainly localized in the transition between the small and large intestine and in the large intestine on the right side.

 For moderate to severe episodes of the disease, the S3 guideline describes treatment with systemic steroids - especially if the inflammation is limited to the right colon area. 

If Crohn's disease causes inflammation in the upper part of the gastrointestinal tract, i.e. the esophagus, stomach or upper small intestine are affected, the following active substances are used to reduce the flare-up and induce remission.

One of these active substances is systemic steroids. According to the S3 guidelines, this form of therapy should be considered if the upper gastrointestinal tract is affected. In the further course, treatment with biologics or TNF-alpha inhibitors can then be considered. It is best to talk to your doctor about this in order to Short bowel syndromepoor absorption of food in the intestine (Malabsorption) or operations.

If steroids do not work in the treatment of a moderate to severe relapse and a remission does not occur within six months, this is a steroid-refractory course of Crohn's disease. According to the guideline, the use of biologics such as TNF-alpha inhibitors can be considered in refractory courses. Talk to your doctor about whether this form of therapy is suitable for you. TNF-alpha inhibitors are used in such cases.

If fistula formation occurs, there are various therapeutic options according to the S3 guideline. These include, for example, local preparations such as rectal foams or suppositories. Here too, your doctor will select the appropriate preparation. If fistula formation occurs, various remedies can be used to treat it. These can be rectal foams, rectal suppositories or enemas.

After successful relapse therapy, remission-preserving treatment should be carried out. The following treatment options are available for this:

Patients who are smokers should be encouraged to stop smoking, as according to the S3 guideline this is a Positive impact on the maintenance of remission. Passive smoking is also harmful and can impair remission maintenance. Both should therefore be avoided for longer remission maintenance.

Whether medication also needs to be taken during remission depends on the severity of the relapses and also the Pre-therapy from. Essentially, however, the consensus according to the guideline is that remission-inducing drugs can be discontinued after a long period of clinically stable remission. 

However, if there is a steroid-dependent course or another risk factor, such as the patient's young age or extensive small bowel involvement, remission-preserving therapy is recommended once remission has been achieved. According to the S3 guideline, combination therapy with infliximab and thiopurines is recommended for patients at risk.

For patients who have a steroid-dependent course, the active substance azathioprine/6-mercaptopurine, for example, is used after the onset of remission. In this case, the active substance is strongly adapted to the previous therapy. Therefore, talk to your doctor about which active ingredient is best suited to your individual therapy plan for your IBD.  

In a nutshell, this means the following for patients diagnosed with Crohn's disease:

• After successful relapse therapy, a Remission-preserving treatment recommended, among others with:
  
  • Azathioprine, 6-mercaptopurine, methotrexate (MTX)
    
  • Biologics: vedolizumab, ustekinumab, TNF-α antibodies
    
  • Upadacitinib, Risankizumab (newly included in the 2024 guideline)
    

• JAK inhibitors (upadacitinib): for refractory courses or steroid intolerance
  
• IL-23 antibodies (Risankizumab): also newly included
  
• Microbiome therapies, stem cell therapy: only in studies
  

• According to the guideline TNF-α antibodies, vedolizumab and ustekinumab can also be used during pregnancy.
  
• Upadacitinib and methotrexate should be avoided
  

Today, Crohn's disease therapy is more individualized than ever. The modern S3 guideline gives doctors clear recommendations, but also leaves room for personal needs, comorbidities and previous treatment experience. Be sure to talk to your specialist about which of the options is right for you.

Can Crohn's disease be cured?
No, not at the moment. The aim is to achieve long-term freedom from symptoms (remission).

What should I do if my medication doesn't help?
There are now many active substances - if there is no response, the treatment can be adjusted individually.

Can I "eat healthy"?
An anti-inflammatory diet can help - but it is no substitute for drug therapy.

How important is the early detection of relapses?
Very important! The earlier it is treated, the better the chances of avoiding complications.

Sturm A, Atreya R, Bettenworth D, et al. Updated S3 guideline "Diagnosis and treatment of Crohn's disease" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - Version 4.1. Z Gastroenterol 2024; 62: 1229-1318. DOI: 10.1055/a-2309-6123.

Lorenz P, Stallmach A, Sturm A, Lynen Jansen P. Guideline report of the updated S3 guideline "Diagnostics and therapy of Crohn's disease" of the DGVS. Z Gastroenterol 2024; 62: e531-e536. DOI: 10.1055/a-2309-6204.

DGVS (ed.). Supplementary material to "Guideline report of the updated S3 guideline Diagnostics and therapy of Crohn's disease". Z Gastroenterol 2024; 62 (Supplement): 1-35. DOI: 10.1055/a-2309-6204 (Appendix 6).