Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021

Abstract

Background: We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD.

Methods: PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021.

Results: Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD.

Conclusions: These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.

Keywords: Consensus; Crohn’s disease; Luminal disease; Treatment escalation/de-escalation.

Fig. 1

Initial assessment and choice of therapy in patients with active fistulizing perianal disease. CRP C-reactive protein, CT computed tomography, EUA examination under anesthesia, IM immunomodulator, MRI magnetic resonance imaging, TNF tumor necrosis factor

Fig. 2

Algorithm for the assessment and management of small bowel stenosis in CD. Dotted lines indicate pathways for patients who show no improvement in obstruction. MRE magnetic resonance enterography

Fig. 3

Algorithm for the monitoring and treatment of patients after intestinal resection in Japan