AGA Institute Guideline on the:

Use of Biologic Drugs for Inflammatory Crohn's Disease: Clinical Decision Support Tool

strong
Strong Recommendation

strong
Weak Recommendation

strong
High-quality Evidence

strong
Moderate-quality Evidence

strong
Low-quality Evidence



Moderately severe Crohn’s disease
despite standard therapies1
Use anti-TNF monotherapy2

Over no therapy

Recommendation 3

Over thiopurine
monotherapy
Recommendation 4

Use anti-TNF + thiopurine2

Over thiopurine
monotherapy
Recommendation 5

Over anti-TNF
monotherapy3
Recommendation 6


REMISSION
Steroid induced
Anti-TNF induced
Anti-TNF + thiopurine induced
Immunomodulator (thiopurine or MTX) over no immunomodulator

Recommendation 7

and

Recommendation 8

Anti-TNF +/- thiopurine4 over no anti-TNF

Recommendation 9


References:
  1. Standard therapies include mesalamine, antibiotics, steroids, immunumodulators.
  2. Induction with a steroid + immunomodulator (thiopurine or MTX) is an option in steroid-responsive patients.
  3. Combination therapy with IFX and AZA is more likely to induce remission than IFX therapy alone. However, significant uncertainty exists regarding the relative value patients place on the greater likelihood of attaining remission with combination therapy, versus the value they place on avoiding the potentially higher risks of serious complications incurred by use of combination therapy.
  4. Combination therapy or anti-TNF monotherapy are appropriate for the maintenance of remission, and we make no recommendation between the two treatment approaches (recommendation 10; no recommendation, low-quality evidence).

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The “AGA Institute Guidelines on the Use of Thiopurines, Methotrexate and Anti-TNF-α Biologic Drugs for the Induction and Maintenance of Remission in Inflammatory Crohn’s Disease” was originally published in Gastroenterology. The citation should state “Terdiman J P et al. American Gastroenterological Association Institute Guideline on the Use of Thiopurines, Methotrexate, and Anti–TNF-α Biologic Drugs for the Induction and Maintenance of Remission in Inflammatory Crohn’s Disease. Gastroenterology 2013;145:1459–1463”

2013 © American Gastroenterological Association

Recommendation 3:


We recommend using anti-TNF- α drugs to induce remission in patients with moderately severe Crohn’s disease.


strong Strong Recommendation; strong Moderate-quality Evidence ×

Recommendation 4:


We recommend using anti-TNF- α monotherapy over thiopurine monotherapy to induce remission in patients who have moderately severe Crohn’s disease.


strong Strong Recommendation; strong Moderate-quality Evidence ×

Recommendation 5:


We recommend using anti-TNF- α drugs in combination with thiopurines over thiopurine monotherapy to induce remission in patients who have moderately severe Crohn’s disease.


strong Strong Recommendation; strong High-quality Evidence ×

Recommendation 6:


We suggest using anti-TNF- α drugs in combination with thiorpurines over anti-TNF- α drug monotherapy to induce remission in patients who have moderately severe Crohn’s disease.3


strong Weak Recommendation; strong Moderate-quality Evidence ×

Recommendation 7:


We recommend using thiopurines over no immunomodulator therapy to maintain a steroidinduced remission in patients with Crohn’s disease.


strong Strong Recommendation; strong Moderate-quality Evidence ×

Recommendation 8:


We suggest using methotrexate over no immunomodulator therapy to maintain a steroidinduced remission in patients with Crohn’s disease.


strong Weak Recommendation; strong Low-quality Evidence ×

Recommendation 9:


We recommend using anti-TNF-α drugs over no anti-TNF-α drugs to maintain a steroid or anti- TNF-α drug-induced remission in patients with Crohn’s disease.


strong Strong Recommendation; strong High-quality Evidence ×

Recommendation 10:


We make no recommendation for or against the combination of an anti-TNF-α drug and a thiopurine versus an anti- TNF-α drug alone to maintain remission induced by a combination of these drugs in patients with Crohn’s disease.


strong Low-quality Evidence ×