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HIBD Horizon

Part 2 · Getting treatment today · 7/22

Crohn's: which treatment for which situation?

How well treatments work depending on what is affected: the bowel, fistulas, after an operation, strictures.

Which treatment works best, and for what?Each situation has its treatments of choice. The levels summarise the European guidelines (ECCO), the large comparisons of studies and the key trials, cited under each card.
Strongest evidence of efficacy
Effective, proven in trials
More limited evidence or supporting role

Mild flare of the ileum

limited, mildly active Crohn's

Strongest evidence of efficacy
BudesonideEntocort, Mikicort
More limited evidence or supporting role
Mesalazinenot very effective in Crohn's
The figures from the trials

Budesonide: about 1 patient in 2 in remission after 8 weeks, versus 1 in 5 without active treatment (disease of the ileum and/or the right colon).

Useful for a flare, not for maintenance: if the flare comes back, you move on to a long-term treatment.

Sources : ECCO 2024; Greenberg, NEJM 1994; Cochrane review

Moderate to severe Crohn's

the most common situation with biologics

Strongest evidence of efficacy
InfliximabRemicadeAdalimumabHumiraRisankizumabSkyriziGuselkumabTremfyaUpadacitinibRinvoq
Effective, proven in trials
UstekinumabStelaraMirikizumabOmvohVedolizumabEntyvio
More limited evidence or supporting role
Azathioprine, methotrexatenot for a flare; useful for maintenance or alongside a biologic
The figures from the trials

In patients never treated with these drugs: infliximab + azathioprine, 57% in steroid-free remission at 6 months, versus 44% with infliximab alone (SONIC).

After an anti-TNF has failed: at 48 weeks, lesions gone or almost gone on colonoscopy in 32% on Skyrizi versus 16% on Stelara (SEQUENCE, patients not blinded).

The large comparisons put anti-TNFs, anti-IL-23s and Rinvoq at the top, with modest differences. Rinvoq requires precautions after age 65, in smokers and in people with heart risk.

Sources : Meta-analyses: Barberio, Gut 2023 and AGA 2025; SONIC, NEJM 2010; SEQUENCE, NEJM 2024

Fistulas near the anus

with or without an abscess

Strongest evidence of efficacy
Anti-TNFespecially RemicadeSurgeondrainage, seton
Effective, proven in trials
UstekinumabStelaraGuselkumabTremfya
More limited evidence or supporting role
UpadacitinibRinvoq, partial dataVedolizumabEntyvioAntibioticsas an add-on
The figures from the trials

Remicade, in those who had responded to the first 3 infusions: fistulas no longer draining at 1 year in 36% versus 19% on placebo (ACCENT II).

Fistula closed and confirmed on MRI: Tremfya 28% versus 10% at 24 weeks (FUZION, results announced by the manufacturer); Stelara 62% versus 25% at 3 months (USTAP, 32 patients).

Always a two-person job: the surgeon drains first, then the long-term treatment heals.

Sources : ECCO 2024; ACCENT II, NEJM 2004; FUZION, DDW congress 2026; USTAP (GETAID), Gut 2026

After an operation

to stop Crohn's coming back

Strongest evidence of efficacy
Anti-TNFRemicade, Humira
Effective, proven in trials
VedolizumabEntyvioAzathioprineImurel, more modest effect
More limited evidence or supporting role
Metronidazolea few monthsStelarano comparative trial yet
The figures from the trials

Remicade: recurrence seen on colonoscopy at 76 weeks (about 18 months) in 31% versus 60% on placebo; relapses with symptoms were not clearly reduced over this period (PREVENT).

Entyvio, in patients at risk: severe recurrence at 6 months in 23% versus 62% on placebo (REPREVIO, 80 patients).

A colonoscopy 6 to 12 months after the operation to check. Stop smoking: tobacco doubles the risk of recurrence.

Sources : ECCO surgery 2024; PREVENT, Gastroenterology 2016; REPREVIO, Lancet Gastroenterol Hepatol 2025

Stricture (narrowing)

depending on whether it is inflammatory or scar tissue

Inflammatory
Biologicespecially anti-TNF
Scar tissue
Dilationduring an endoscopySurgeryresection, strictureplasty
Tomorrow
Anti-fibrosisin trials (sheet 18)
The figures from the trials

Humira in a stricture with symptoms: success at 6 months in 64% of patients, with no operation or dilation (CREOLE study, no comparison group).

MRI or ultrasound help to tell how much is inflammation and how much is scar tissue.

Sources : ECCO 2024; CREOLE (GETAID), Gut 2018

Read this before comparingThis is not a personal ranking. The percentages come from trials in selected patients, often compared with a placebo: in real life, and after several treatments, they are often lower. The differences between treatments are often small, and they were measured in different studies. The best treatment for you depends on where the disease is, your past treatments, your other health problems and your plans. A “lower-ranked” treatment may be the right one for you. Some figures come from small trials or recent congresses and may change.