Update on long-term management in Crohn's disease

The principal challenge in managing chronic Crohn's disease is the maintenance of long-term remission. Continued active therapy is perhaps the simplest and most common in everyday practice, and is the continuation of the same medications that have already proved successful in inducing remission acutely. Aminosalicylates, mesalazine for example, may be suitable for this purpose, although the cost-effectiveness is low because the NNT (number needed-to-treat) is quite high. On the other hand, newer corticosteroids, such as budesonide, although effective in acute disease, have not established a role in long-term management. Another strategy refers to switching from a previous remission-inducing therapy to a different treatment. The most obvious example of this approach is the introduction of antimetabolite medications, such as azathioprine, 6-mercaptopurine and methotrexate. All these drugs have been shown to maintain remission following an acute course of steroid treatment. Infliximab is also effective at maintaining remission, although the duration of effect diminishes over time. It is indicative of the chronic nature of this disease that such an array of therapies has been used over the years. Most recently, promising results have been reported in unblinded or uncontrolled studies of dietary manipulations, probiotics and immunomodulators. However, these observations have not yet been confirmed by randomised controlled studies.