This paper is the second in a series of three publications relating to the European evidence-based consensus on the diagnosis and management of Crohn's disease and concerns the management of active disease, maintenance of medically induced remission and surgery. The aims and methods of the ECCO Consensus, as well as sections on diagnosis and classification are covered in the first paper [van Assche et al. JCC 2009a]. The final paper covers post-operative recurrence, fistulating disease, the management of paediatric and adolescent IBD, pregnancy, psychosomatics, extraintestinal manifestations and complementary or alternative therapy for Crohn's disease [Van Assche et al JCC 2009b]. #### Principal changes with respect to the 2006 ECCO guidelines

The early use of azathioprine/mercaptopurine or methotrexate in combination with steroids is an appropriate option in moderately active localised ileocaecal CD. Anti-TNF therapy should be considered as an alternative for patients with objective evidence of active disease who have previously been steroid-refractory, steroid-dependent, or steroid-intolerant (based on Statement 5B).

For those patients with severely active localised ileocaecal Crohn's disease and objective evidence of active disease who have relapsed, anti-TNF therapy with or without an immunomodulator is an appropriate option [EL1a, RG B for infliximab]. For some patients who have infrequently relapsing disease, restarting steroids with an immunomodulator may be appropriate (based on Statement 5C).

All currently available anti-TNF therapies appear to have generally similar efficacy and adverse-event profiles for inflammatory (‘luminal’) Crohn's disease, so the choice depends on availability, route of delivery, patient preference, cost and national guidelines \[EL5, RG D\] (Statement 5I).

Patients receiving azathioprine or mercaptopurine who relapse should be evaluated for adherence to therapy and have their dose optimised. Changing their maintenance therapy to methotrexate [EL1b RG B] or anti-TNF therapy [EL1a RGB] should be considered. Surgery should always be considered as an option in localised disease [EL4, …

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The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Current management

This second section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns treatment of active disease, maintenance of medically induced remission, and surgery. The first section on definitions and diagnosis includes the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The third section on special situations in Crohn's disease includes postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy for Crohn's disease.

https://gut.bmj.com/content/gutjnl/55/suppl_1/i16.full.pdf

European evidence based consensus on the diagnosis and management of Crohn’s disease: current management

Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis.

https://www.spg.pt/wp-content/uploads/2015/11/2012_UC_Consensus_1_Definitions_and_diagnosis.pdf

European evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis

### 5.1 General

The general principles for treating active ulcerative colitis are to consider the activity, distribution (proctitis, left-sided, extensive,1 and pattern of disease (relapse frequency, course of disease, response to previous medications, side-effect profile of medication, extra-intestinal manifestation), before treatment decisions are made in conjunction with the patient.

#### 5.1.1 Disease activity

The principal scoring systems used for clinical trials are covered in Section 5.1.2 and have been comprehensively reviewed.2 Some additional points are clinically relevant. In clinical practice it matters most to distinguish severe ulcerative colitis necessitating hospital admission from those with mild or moderate disease who can generally be treated as outpatients. The simplest, best validated and most widely used index for identifying acute severe UC remains that of Truelove & Wi_tts 3: any patient who has a bloody stool frequency ≥ 6/day and a tachycardia (> 90 bpm), or temperature > 37.8 °C, or anaemia (haemoglobin 30 mm/h) has severe ulcerative colitis (Table 1.3). This index has been used in 20/32 studies of intensive intravenous treatment for severe UC.4 Only one additional criterion in addition to the bloody stool frequency ≥ 6/day is needed to define a severe attack.5 While these criteria have the major limitation of being unresponsive and cannot track the course of disease, they do distinguish the severe from the moderate or mild and have value in everyday practice because they are easy to use, which no other index achieves. It should be standard practice to confirm active colitis by sigmoidoscopy or proctoscopy before starting treatment. Rectal mucosal biopsy helps exclude unexpected causes of symptoms similar to active disease (such as cytomegalovirus, amoebic, or other infection, rectal mucosal prolapse, Crohn's disease, or even irritable bowel syndrome and haemorrhoidal bleeding).

#### 5.1.2 Approach

Patients should be encouraged to participate actively in …

/pdf/european-evidence-based-consensus-on-the-management-of-3oopv702qw.pdf

European evidence-based Consensus on the management of ulcerative colitis: Current management.

Summary

Background

Corticosteroids remain the mainstay of first-line therapy in active inflammatory bowel disease



Aims

To determine the clinical outcome after the first corticosteroid-therapy and to identify factors which predict response/failure



Methods

216 (136 ulcerative colitis and 80 Crohn's disease) patients were identified in this 5-year inception cohort The outcomes of early (30 days) and late (1 year) responses were used Multivariate analyses were performed to identify factors associated with outcome



Results

86 (63%) and 60 (75%) ulcerative colitis and Crohn's disease required corticosteroid therapy, respectively In ulcerative colitis, at 30 days, 69 (51%), 42 (31%) and 25 (18%) patients demonstrated complete response, partial response and no response, respectively For Crohn's disease, these outcomes were observed in 32 (40%), 28 (35%) and 20 (25%) After 1 year, 75 (55%), 23 (17%) and 29 (21%) patients with ulcerative colitis demonstrated prolonged response, corticosteroid-dependence or required surgery, respectively For Crohn's disease, these outcomes were observed in 30 (38%), 19 (24%) and 27 (35%) patients Extensive ulcerative colitis was a predictor of surgery (P = 0001, OR: 152) In Crohn's disease, inflammatory disease behaviour was negatively associated with surgery (P = 002, OR: 013)



Conclusion

Although corticosteroids are effective, dependence/resistance remains common Patients with extensive ulcerative colitis and fistulizing/stricturing Crohn's are most at risk of failing corticosteroid therapy

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2036.2006.02974.x

P. Chiam

Papers

The efficacy of corticosteroid therapy in inflammatory bowel disease: analysis of a 5‐year UK inception cohort