The pharmacotherapeutic management of pediatric Crohn’s disease

ABSTRACT

Introduction: Crohn’s disease (CD) is a chronic inflammatory condition that can occur throughout the gastrointestinal tract. The aims of treatment of children with CD are to induce and maintain clinical remission of disease, optimize nutrition and growth, minimize adverse effects of therapies, and if possible, achieve mucosal healing.

Areas covered: This review summarizes evidence for the various therapeutic options in the treatment of children with CD. Exclusive enteral nutrition, corticosteroids, and biologics may be used for induction of remission. Immunomodulators (thiopurines, methotrexate) and biologics (infliximab, adalimumab) may be employed for maintenance of remission to prevent flares of disease and avoid chronic steroid use. In cases of fibrotic disease, intestinal perforations, or medically refractory, surgery may be the best therapeutic option.

Expert opinion: Exclusive enteral nutrition, corticosteroids, and biologics (including anti-TNF inhibitors) may be used for induction of remission in patients with active flare of their disease. Immunomodulators and TNF inhibitors may be used for maintenance of remission. Early use of anti-TNF inhibitors in patients with moderate to severe CD may improve efficacy and prevent penetrating complications of disease. While pediatric data is limited, newer biologics, such as vedolizumab and ustekinumab, are used off-label in anti-TNF refractory disease.

KEYWORDS:

• Crohn’s disease
• pediatric
• child
• treatment

Article highlights

• For induction of remission, children with active Crohn’s disease may be treated with exclusive enteral nutrition, corticosteroids, or biologic therapies (e.g. infliximab and adalimumab).

• For maintenance of remission, aminosalicylates, immunomodulators (including methotrexate or thiopurines), and biologics (notably TNF-inhibitors) are utilized to prevent flares of the disease.

• Immunomodulators may be used in combination with biologics to reduce immunogenicity and increase efficacy of therapy but toxicity must be weighed against benefit of therapy.

• Therapeutic drug monitoring is utilized to optimize therapy for thiopurines and TNF inhibitors (including infliximab and adalimumab).

• Early use of anti-TNF inhibitors in children with moderate to severe Crohn’s disease may improve efficacy and prevent penetrating complications of disease.

• Surgery is used to treat children with Crohn’s disease who have medically refractory disease, stricture, or penetrating complication of the disease.

This box summarizes key points contained in the article.

Declaration of interest

A Bousvaros has received research support from Prometheus, Janssen Pharmaceuticals, AbbVie, Takeda and Buhlmann Laboratories. They’ve also received consultancy fees from Shire, Takeda, Best Doctors and Alivio and honoraria and royalties from UptoDate, Boston University and Nutricia. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.