Algorithm for management of ileocolonic Crohn disease in children

EEN: exclusive enteral nutrition; anti-TNF: anti-tumor necrosis factor; IFX: infliximab; 6-MP: 6-mercaptopurine; AZA: azathioprine; MTX: methotrexate; PEN: partial enteral nutrition; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein.
* Preliminary studies suggest that PEN with a specific exclusion diet may be as effective and better accepted by patients than EEN^[1].
¶ For patients with severe disease, enteral nutrition therapy might be used in combination with glucocorticoids or other medical treatments for induction of remission.
Δ Although aminosalicylates are attractive because of low toxicity, it is unclear if these drugs are superior to placebo in preventing relapse. As a result, immunomodulators (6-MP/AZA or MTX) or anti-TNF antibodies are generally used for maintenance therapy for patients with moderate or severe disease.
◊ Many clinicians prefer to avoid thiopurines (6-MP/AZA) because of the slight increase in absolute risk for lymphoma and nonmelanoma skin cancers. The debate continues on the benefit-to-risk ratio of thiopurines. MTX or early use of anti-TNF therapies are increasingly being utilized as alternatives.
§ Early use of anti-TNF antibodies (ie, for initial induction or first step in maintenance) is a reasonable option for patients with moderate to severe CD. This is especially appropriate for patients with the following characteristics, which suggest high risk for complicated disease^[2-4]:

• Severe perianal disease
• Steroid-unresponsive
• Deep fissuring ulcers in the colon
• Extensive disease involving the mid-small bowel
• Growth failure (if severe and/or occurring in late puberty)

¥ Relapse may include clinical symptoms of Crohn disease or other evidence of persistent disease activity including laboratory evidence of persistent inflammation (elevated ESR or CRP) or findings from endoscopy or imaging.
‡ In general, patients requiring more than 1 course of glucocorticoids within 1 year should be advanced to a different immunomodulator or to an anti-TNF antibody.