The initial choice of
therapy for mild to moderately active
Crohn's disease is controversial. Both the National Cooperative
Crohn's Disease Study (NCCDS) and the European Cooperative
Crohn's Disease Study (ECCDS) demonstrated that
sulfasalazine is effective for the
induction of remission. Subsequent studies of new
mesalamine formulations showed inconsistent results; two trials, however, demonstrated a statistically significant improvement with
Pentasa and
Asacol treatment, and meta-analyses suggest a modest benefit of
mesalamine maintenance
therapy. The NCCDS and ECCDS trials found that
corticosteroid therapy is much more effective than
sulfasalazine for
induction of remission, but
corticosteroids did not show maintenance benefits.
Corticosteroid use is frequently associated with adverse effects, and the majority of patients treated with
prednisone become either
steroid-refractory or
steroid-dependent; many of these patients ultimately need treatment with immunosuppressives and/or surgery.
Budesonide, a topical
corticosteroid with high first-pass hepatic metabolism, is slightly less effective in inducing remission than conventional
corticosteroids but is significantly less likely to cause side effects.
Budesonide 9 mg/day was shown to be more effective than
mesalamine (
Pentasa 4 g/day) for induction
therapy, but
budesonide has been ineffective as a maintenance
therapy.
Mesalamine may be useful for patients with more extensive disease, those intolerant of
sulfasalazine, or those with
contraindications or intolerance to
budesonide. Alternatively,
sulfasalazine is effective in the presence of
colonic disease. Clinicians must decide on the basis of the existing evidence whether
budesonide or
mesalamine is the preferred initial
therapy for active
Crohn's disease.