Recommendation ID

What are the benefits, risk and cost effectiveness of enteral nutrition in maintaining remission in the post-surgical period of Crohn's disease?

Any explanatory notes
(if applicable)

The recommendations apply to people with ileocolonic Crohn's disease who have had complete
macroscopic resection and who have no residual active disease. This is the population covered in
the studies the committee reviewed. The committee was aware that a proportion of people could
still have residual active disease after surgery. It agreed that in these people, their disease is not in
remission and the recommendations for inducing remission in section 1.2 would apply.
The evidence showed that azathioprine in combination with up to 3 months' metronidazole was
effective in maintaining endoscopic remission. While there was some evidence of clinical benefit
with azathioprine on its own, the effect was less certain. However, the committee included it as an
option because some people have trouble tolerating metronidazole. The committee did not
recommend metronidazole alone because, based on the evidence and their clinical experience, the
potential benefits did not outweigh the potential harms (or adverse effects). Azathioprine can also
be difficult to tolerate, and can cause adverse effects, so the committee looked at mercaptopurine
as an alternative. However, mercaptopurine is not cost effective for maintaining remission because
it has a high cost relative to the limited benefits it provides. The committee also reviewed the
evidence for aminosalicylates (such as mesalazine). The evidence on relapse rates (assessed
endoscopically) showed that aminosalicylates were not clinically or cost effective. Because of this,
the 2012 recommendation on aminosalicylates was removed.
The committee made a recommendation on monitoring because of the tolerability issues and
potential adverse effects of azathioprine and metronidazole. This is based on the 2012
recommendation on monitoring azathioprine when using it to induce remission.
There was limited evidence available for biologics, and a lot of uncertainty around how much
benefit they provide. Biologics are also expensive, and all these factors together mean that they are
not currently cost effective when compared with the other options for maintaining remission. To
avoid unnecessarily changing treatments for people who started taking biologics before this
guideline was published, the committee made a recommendation to cover this group.
The committee made a recommendation against offering budesonide because evidence shows that
it is not beneficial in maintaining remission after surgery.
None of the included studies looked specifically at maintaining remission for children and young
people after surgery, so the committee did not make separate recommendations for this
population. In their experience children and young people are offered the same post-surgery
treatment as adults.
There was no randomised controlled trial evidence on enteral nutrition. The committee
recommended further research on this because it is sometimes used alone or with other
maintenance therapy for maintaining remission after surgery.
How the recommendations might affect practice
The committee noted that the recommendations made are in line with current practice. There is
variation across the UK in whether people receive 3 months of metronidazole after surgery.
The committee believe that the recommendation to not start biologics after surgery could
potentially result in cost savings and maintain consistency in clinical practice.
Full details of the evidence and the committee's discussion are in the evidence review: Crohn's
disease management – post surgical maintenance of remission.

Source guidance details

Comes from guidance
Crohn’s disease: management
Date issued
May 2019

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 01/05/2019