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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 42-year-old woman is evaluated in follow-up after being diagnosed with Crohn disease 8 months ago. Her disease is predominantly localized to the ileum, and she has no fistulous disease. She has completed two courses of antimicrobial therapy with no improvement in her symptoms. She experienced symptom relief with the use of oral prednisone, but her symptoms recurred when the prednisone dose was tapered. She currently has moderate abdominal pain, arthralgia, and four liquid stools per day, and she describes her well-being as poor. Her medications are prednisone, 20 mg/d, and loperamide as needed.

On physical examination, temperature 36.8°C (98.2°F), blood pressure is 115/76 mm Hg, and pulse rate is 88/min; BMI is 19. Abdominal examination reveals moderate tenderness to palpation but no rebound tenderness or guarding. No abdominal masses are noted.


Which of the following is the most appropriate treatment?

The most appropriate treatment is anti-tumor necrosis factor (anti-TNF) therapy. This patient has refractory, moderately severe Crohn disease (CD), as evidenced by her glucocorticoid dependence and repeated relapses despite first-line treatments. Typical first-line agents for initial management of uncomplicated moderately severe CD may include oral budesonide or 5-aminosalicylic acid (5-ASA) therapy, although the effectiveness of 5-ASA in CD has been questioned. These agents are augmented with the use of antimicrobial therapy (which have both anti-infective and anti-inflammatory properties) or systemic prednisone based on symptoms and provider preference. However, CD that is refractory to initial therapy is treated differently than uncomplicated newly diagnosed disease. There is significant controversy over which agent should be used as first-line treatment of refractory CD, but the consensus is that anti-TNF therapy is reasonable in this setting. The recently published American Gastroenterological Association guidelines for treatment of CD make a strong recommendation based on moderate-quality evidence that anti-TNF therapy is desirable in patients with moderately severe CD refractory to other therapies. Other guidelines recommend azathioprine or 6-mercaptopurine as first-line treatment for refractory disease, although anti-TNF therapies appear to work faster than these agents and therefore may be preferred in patients such as this one with moderate or severe symptoms. Methotrexate can also be considered, especially if arthropathy is prominent, but it has weaker evidence in this setting. With all of these drugs, the benefit of inducing remission must be weighed against the significant side effects.

Although 5-ASA preparations and oral budesonide may be used as initial therapy, neither has a role in the treatment of refractory CD.

Glucocorticoid enemas are sometimes used in the treatment of inflammatory bowel disease limited to the distal colon or rectum. This patient has predominantly ileal disease, so enemas would not be expected to help.

Key Point

  • Some guidelines recommend anti-tumor necrosis factor agents as first-line therapy in refractory Crohn disease, whereas others recommend azathioprine or 6-mercaptopurine as first-line therapy.
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