Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease

Remo Panaccione; A. Hillary Steinhart; B. Bressler; R. Khanna; John K. Marshall; L. Targownik; Waqqas Afif; A. Bitton; Mark Borgaonkar; Usha Chauhan; Brendan Halloran; Jennifer Jones; Erin Kennedy; Grigorios I. Leontiadis; Edward V. Loftus; Jonathan Meddings; Paul Moayyedi; Sanjay Murthy; Sophie Plamondon; Greg Rosenfeld; D. Schwartz; Cynthia H. Seow; Chadwick Williams; Charles N. Bernstein

doi:10.1016/j.cgh.2019.02.043

Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease

Remo Panaccione, A. Hillary Steinhart, B. Bressler, R. Khanna, John K. Marshall, L. Targownik, Waqqas Afif, A. Bitton, Mark Borgaonkar, Usha Chauhan, Brendan Halloran, Jennifer Jones, Erin Kennedy, Grigorios I. Leontiadis, Edward V. Loftus, Jonathan Meddings, Paul Moayyedi, Sanjay Murthy, Sophie Plamondon, Greg RosenfeldD. Schwartz, Cynthia H. Seow, Chadwick Williams, Charles N. Bernstein

Medicine

Research output: Contribution to journal › Article › peer-review

26 Citations (Scopus)

Abstract

Background & Aims: Crohn's disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. Methods: We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. Results: The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. Conclusions: Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.

Original language	English
Pages (from-to)	1680-1713
Number of pages	34
Journal	Clinical Gastroenterology and Hepatology
Volume	17
Issue number	9
DOIs	https://doi.org/10.1016/j.cgh.2019.02.043
Publication status	Published - Aug 2019

Bibliographical note

Funding Information:
Funding for the consensus meeting was provided by unrestricted, arms-length grants to the CAG by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc. The CAG administered all aspects of the meeting, and the funding sources had no involvement in the process at any point, and they were not made aware of any part of the process from development of search strings and the statements to drafting and approval of these guidelines.

Funding Information:
Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. Conflicts of interest These authors disclose the following: Advisory board: AbbVie (AB, AHS, BB, BH, CB, CS, CW, GR, LT, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (AHS, BB, CS), Allergan (AB), Amgen (RP), Aptalis (RP), AstraZeneca (RP), Baxter (RP), Bristol-Myers Squibb (RP), Celgene (RP), Celltrion (BB), Centocor (RP), Cubist (CB, RP), Eisai (RP), Elan (RP), Ferring (AB, AHS, BB, CW, RP, WA), Genentech (BB, RP), Glaxo-Smith Kline (RP), Janssen (AB, AHS, BH, CS, GR, LT, RK, RP, SP, UC, WA), Merck (AB, AHS, RP), Pendopharm (AHS, BB, GR), Pfizer (AB, AHS, RP), Salix (RP), Schering-Plough (RP), Shire (AB, AHS, BB, CB, CS, CW, GR, MB, RP, SM, WA), Takeda (AB, AHS, BB, CB, CS, GR, JJ, LT, RK, RP, SM, SP, UC, WA), UCB (RP), Warner Chilcott (RP). Consulting: AbbVie (DS, GR, JJ, EL, JKM, RP), Abbott (RP), Actavis (JKM), Amgen (EL, RP), Aptalis (RP), AstraZeneca (JKM, RP), Baxter (RP), Bristol-Myers Squibb (EL, RP), Celgene (EL, RP), Celltrion (JKM), Centocor (RP), Cubist (JKM, RP), CVS Caremark (EL), Eisai (RP), Elan (RP), Eli Lilly (EL), Ferring (JKM, RP), Genentech (EL), Glaxo-Smith Kline (RP), Hospira (JKM), Janssen (DS, JJ, EL, JKM, RP), Merck (RP), Mesoblast (EL), Pfizer (AHS, EL, RP), Salix (EL), Schering-Plough (RP), Seres Therapeutics (EL), Shire (JKM, RP), Sun Pharmaceuticals (EL), Takeda (DS, JJ, EL, JKM, RP), Theradig (CB, EL), Tigenix (DS), UCB (EL, RP, DS), Warner Chilcott (RP). Educational support: AbbVie (AB, RP, SP, UC), Abbott (RP), Allergan (AB), Aptalis (UC), Bristol-Myers Squibb (RP), Centocor (RP), Elan (RP), Ferring (RP), Janssen (AB, AHS, GR, RP), Millennium (RP), Pfizer (LT), Proctor and Gamble (RP), Schering-Plough (RP), Shire (LT), Takeda (AB, LT). Research grants/clinical trial funding: AbbVie (AB, AHS, BB, EL, DS, LT, RP), Abbott (RP), Alvine (BB), Amgen (AHS, BB, EL), Boehringer Ingelheim (BB), Bristol-Myers Squibb (BB, RP), Celgene (AHS, BB, EL), Centocor (RP), Elan (RP), Ferring (RP), Genentech (AHS, BB, EL), Gilead (EL), Glaxo-Smith Kline (BB), Janssen (BB, EL, RP), MedImmune (EL), Merck (BB), Millennium (AHS, RP), Pfizer (EL, LT), Proctor and Gamble (RP), Prometheus (WA), Qu Biologic (BB), Receptos (EL), RedHill Biopharm (AHS, BB), Robarts Clinical Trials (EL), Schering-Plough (RP), Seres Therapeutics (EL), Takeda (EL), UCB (EL, DS). Speaker's bureau: AbbVie (AB, AHS, BB, BH, CB, GR, JKM, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (BB, JKM), Allergan/Forest (MB), Aptalis (UC), AstraZeneca (RP), Centocor (RP), Elan (RP), Ferring (AHS, BB, JJ, JKM), Hospira (AHS, JKM), Janssen (AHS, BH, CB, CW, GR, JJ, JKM, MB, RK, RP, SP, UC, WA), Pendopharm (BH, MB), Prometheus (RP), Schering-Plough (RP), Shire (AB, AHS, BB, BH, CB, GR, JJ, JKM, MB, RP, SP), Takeda (AB, AHS, BB, CB, CW, GR, JKM, MB, RK, RP, SM, WA), Warner Chilcott (RP). Other: Qu Biologic (BB-stock options). The remaining authors disclose no conflicts. Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. The Canadian Association of Gastroenterology thanks AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc for their generous support of the guideline process. The consensus group would like to thank the following people for their contributions: Paul Sinclair and Lesley Marshall (CAG representatives, administrative and technical support, and logistics assistance), Pauline Lavigne and Steven Portelance (unaffiliated, editorial assistance). Finally, they thank their patient advocate, Jenna Rines, for invaluable insights. Conflicts of interest These authors disclose the following: Advisory board: AbbVie (AB, AHS, BB, BH, CB, CS, CW, GR, LT, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (AHS, BB, CS), Allergan (AB), Amgen (RP), Aptalis (RP), AstraZeneca (RP), Baxter (RP), Bristol-Myers Squibb (RP), Celgene (RP), Celltrion (BB), Centocor (RP), Cubist (CB, RP), Eisai (RP), Elan (RP), Ferring (AB, AHS, BB, CW, RP, WA), Genentech (BB, RP), Glaxo-Smith Kline (RP), Janssen (AB, AHS, BH, CS, GR, LT, RK, RP, SP, UC, WA), Merck (AB, AHS, RP), Pendopharm (AHS, BB, GR), Pfizer (AB, AHS, RP), Salix (RP), Schering-Plough (RP), Shire (AB, AHS, BB, CB, CS, CW, GR, MB, RP, SM, WA), Takeda (AB, AHS, BB, CB, CS, GR, JJ, LT, RK, RP, SM, SP, UC, WA), UCB (RP), Warner Chilcott (RP). Consulting: AbbVie (DS, GR, JJ, EL, JKM, RP), Abbott (RP), Actavis (JKM), Amgen (EL, RP), Aptalis (RP), AstraZeneca (JKM, RP), Baxter (RP), Bristol-Myers Squibb (EL, RP), Celgene (EL, RP), Celltrion (JKM), Centocor (RP), Cubist (JKM, RP), CVS Caremark (EL), Eisai (RP), Elan (RP), Eli Lilly (EL), Ferring (JKM, RP), Genentech (EL), Glaxo-Smith Kline (RP), Hospira (JKM), Janssen (DS, JJ, EL, JKM, RP), Merck (RP), Mesoblast (EL), Pfizer (AHS, EL, RP), Salix (EL), Schering-Plough (RP), Seres Therapeutics (EL), Shire (JKM, RP), Sun Pharmaceuticals (EL), Takeda (DS, JJ, EL, JKM, RP), Theradig (CB, EL), Tigenix (DS), UCB (EL, RP, DS), Warner Chilcott (RP). Educational support: AbbVie (AB, RP, SP, UC), Abbott (RP), Allergan (AB), Aptalis (UC), Bristol-Myers Squibb (RP), Centocor (RP), Elan (RP), Ferring (RP), Janssen (AB, AHS, GR, RP), Millennium (RP), Pfizer (LT), Proctor and Gamble (RP), Schering-Plough (RP), Shire (LT), Takeda (AB, LT). Research grants/clinical trial funding: AbbVie (AB, AHS, BB, EL, DS, LT, RP), Abbott (RP), Alvine (BB), Amgen (AHS, BB, EL), Boehringer Ingelheim (BB), Bristol-Myers Squibb (BB, RP), Celgene (AHS, BB, EL), Centocor (RP), Elan (RP), Ferring (RP), Genentech (AHS, BB, EL), Gilead (EL), Glaxo-Smith Kline (BB), Janssen (BB, EL, RP), MedImmune (EL), Merck (BB), Millennium (AHS, RP), Pfizer (EL, LT), Proctor and Gamble (RP), Prometheus (WA), Qu Biologic (BB), Receptos (EL), RedHill Biopharm (AHS, BB), Robarts Clinical Trials (EL), Schering-Plough (RP), Seres Therapeutics (EL), Takeda (EL), UCB (EL, DS). Speaker's bureau: AbbVie (AB, AHS, BB, BH, CB, GR, JKM, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (BB, JKM), Allergan/Forest (MB), Aptalis (UC), AstraZeneca (RP), Centocor (RP), Elan (RP), Ferring (AHS, BB, JJ, JKM), Hospira (AHS, JKM), Janssen (AHS, BH, CB, CW, GR, JJ, JKM, MB, RK, RP, SP, UC, WA), Pendopharm (BH, MB), Prometheus (RP), Schering-Plough (RP), Shire (AB, AHS, BB, BH, CB, GR, JJ, JKM, MB, RP, SP), Takeda (AB, AHS, BB, CB, CW, GR, JKM, MB, RK, RP, SM, WA), Warner Chilcott (RP). Other: Qu Biologic (BB-stock options). The remaining authors disclose no conflicts. Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development.

Funding Information:
Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. The Canadian Association of Gastroenterology thanks AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc for their generous support of the guideline process. The consensus group would like to thank the following people for their contributions: Paul Sinclair and Lesley Marshall (CAG representatives, administrative and technical support, and logistics assistance), Pauline Lavigne and Steven Portelance (unaffiliated, editorial assistance). Finally, they thank their patient advocate, Jenna Rines, for invaluable insights.

Publisher Copyright:
© 2019 AGA Institute and the Canadian Association of Gastroenterology

ASJC Scopus Subject Areas

Hepatology
Gastroenterology

PubMed: MeSH publication types

Journal Article
Practice Guideline
Research Support, Non-U.S. Gov't

Access to Document

10.1016/j.cgh.2019.02.043

Cite this

Panaccione, R., Steinhart, A. H., Bressler, B., Khanna, R., Marshall, J. K., Targownik, L., Afif, W., Bitton, A., Borgaonkar, M., Chauhan, U., Halloran, B., Jones, J., Kennedy, E., Leontiadis, G. I., Loftus, E. V., Meddings, J., Moayyedi, P., Murthy, S., Plamondon, S., ... Bernstein, C. N. (2019). Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease. Clinical Gastroenterology and Hepatology, 17(9), 1680-1713. https://doi.org/10.1016/j.cgh.2019.02.043

Panaccione, R, Steinhart, AH, Bressler, B, Khanna, R, Marshall, JK, Targownik, L, Afif, W, Bitton, A, Borgaonkar, M, Chauhan, U, Halloran, B, Jones, J, Kennedy, E, Leontiadis, GI, Loftus, EV, Meddings, J, Moayyedi, P, Murthy, S, Plamondon, S, Rosenfeld, G, Schwartz, D, Seow, CH, Williams, C & Bernstein, CN 2019, 'Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease', Clinical Gastroenterology and Hepatology, vol. 17, no. 9, pp. 1680-1713. https://doi.org/10.1016/j.cgh.2019.02.043

@article{337b84bf184f47c9b0fcf02254820b50,

title = "Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease",

abstract = "Background & Aims: Crohn's disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. Methods: We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. Results: The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. Conclusions: Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.",

author = "Remo Panaccione and Steinhart, {A. Hillary} and B. Bressler and R. Khanna and Marshall, {John K.} and L. Targownik and Waqqas Afif and A. Bitton and Mark Borgaonkar and Usha Chauhan and Brendan Halloran and Jennifer Jones and Erin Kennedy and Leontiadis, {Grigorios I.} and Loftus, {Edward V.} and Jonathan Meddings and Paul Moayyedi and Sanjay Murthy and Sophie Plamondon and Greg Rosenfeld and D. Schwartz and Seow, {Cynthia H.} and Chadwick Williams and Bernstein, {Charles N.}",

note = "Funding Information: Funding for the consensus meeting was provided by unrestricted, arms-length grants to the CAG by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc. The CAG administered all aspects of the meeting, and the funding sources had no involvement in the process at any point, and they were not made aware of any part of the process from development of search strings and the statements to drafting and approval of these guidelines. Funding Information: Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. Conflicts of interest These authors disclose the following: Advisory board: AbbVie (AB, AHS, BB, BH, CB, CS, CW, GR, LT, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (AHS, BB, CS), Allergan (AB), Amgen (RP), Aptalis (RP), AstraZeneca (RP), Baxter (RP), Bristol-Myers Squibb (RP), Celgene (RP), Celltrion (BB), Centocor (RP), Cubist (CB, RP), Eisai (RP), Elan (RP), Ferring (AB, AHS, BB, CW, RP, WA), Genentech (BB, RP), Glaxo-Smith Kline (RP), Janssen (AB, AHS, BH, CS, GR, LT, RK, RP, SP, UC, WA), Merck (AB, AHS, RP), Pendopharm (AHS, BB, GR), Pfizer (AB, AHS, RP), Salix (RP), Schering-Plough (RP), Shire (AB, AHS, BB, CB, CS, CW, GR, MB, RP, SM, WA), Takeda (AB, AHS, BB, CB, CS, GR, JJ, LT, RK, RP, SM, SP, UC, WA), UCB (RP), Warner Chilcott (RP). Consulting: AbbVie (DS, GR, JJ, EL, JKM, RP), Abbott (RP), Actavis (JKM), Amgen (EL, RP), Aptalis (RP), AstraZeneca (JKM, RP), Baxter (RP), Bristol-Myers Squibb (EL, RP), Celgene (EL, RP), Celltrion (JKM), Centocor (RP), Cubist (JKM, RP), CVS Caremark (EL), Eisai (RP), Elan (RP), Eli Lilly (EL), Ferring (JKM, RP), Genentech (EL), Glaxo-Smith Kline (RP), Hospira (JKM), Janssen (DS, JJ, EL, JKM, RP), Merck (RP), Mesoblast (EL), Pfizer (AHS, EL, RP), Salix (EL), Schering-Plough (RP), Seres Therapeutics (EL), Shire (JKM, RP), Sun Pharmaceuticals (EL), Takeda (DS, JJ, EL, JKM, RP), Theradig (CB, EL), Tigenix (DS), UCB (EL, RP, DS), Warner Chilcott (RP). Educational support: AbbVie (AB, RP, SP, UC), Abbott (RP), Allergan (AB), Aptalis (UC), Bristol-Myers Squibb (RP), Centocor (RP), Elan (RP), Ferring (RP), Janssen (AB, AHS, GR, RP), Millennium (RP), Pfizer (LT), Proctor and Gamble (RP), Schering-Plough (RP), Shire (LT), Takeda (AB, LT). Research grants/clinical trial funding: AbbVie (AB, AHS, BB, EL, DS, LT, RP), Abbott (RP), Alvine (BB), Amgen (AHS, BB, EL), Boehringer Ingelheim (BB), Bristol-Myers Squibb (BB, RP), Celgene (AHS, BB, EL), Centocor (RP), Elan (RP), Ferring (RP), Genentech (AHS, BB, EL), Gilead (EL), Glaxo-Smith Kline (BB), Janssen (BB, EL, RP), MedImmune (EL), Merck (BB), Millennium (AHS, RP), Pfizer (EL, LT), Proctor and Gamble (RP), Prometheus (WA), Qu Biologic (BB), Receptos (EL), RedHill Biopharm (AHS, BB), Robarts Clinical Trials (EL), Schering-Plough (RP), Seres Therapeutics (EL), Takeda (EL), UCB (EL, DS). Speaker's bureau: AbbVie (AB, AHS, BB, BH, CB, GR, JKM, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (BB, JKM), Allergan/Forest (MB), Aptalis (UC), AstraZeneca (RP), Centocor (RP), Elan (RP), Ferring (AHS, BB, JJ, JKM), Hospira (AHS, JKM), Janssen (AHS, BH, CB, CW, GR, JJ, JKM, MB, RK, RP, SP, UC, WA), Pendopharm (BH, MB), Prometheus (RP), Schering-Plough (RP), Shire (AB, AHS, BB, BH, CB, GR, JJ, JKM, MB, RP, SP), Takeda (AB, AHS, BB, CB, CW, GR, JKM, MB, RK, RP, SM, WA), Warner Chilcott (RP). Other: Qu Biologic (BB-stock options). The remaining authors disclose no conflicts. Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. The Canadian Association of Gastroenterology thanks AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc for their generous support of the guideline process. The consensus group would like to thank the following people for their contributions: Paul Sinclair and Lesley Marshall (CAG representatives, administrative and technical support, and logistics assistance), Pauline Lavigne and Steven Portelance (unaffiliated, editorial assistance). Finally, they thank their patient advocate, Jenna Rines, for invaluable insights. Conflicts of interest These authors disclose the following: Advisory board: AbbVie (AB, AHS, BB, BH, CB, CS, CW, GR, LT, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (AHS, BB, CS), Allergan (AB), Amgen (RP), Aptalis (RP), AstraZeneca (RP), Baxter (RP), Bristol-Myers Squibb (RP), Celgene (RP), Celltrion (BB), Centocor (RP), Cubist (CB, RP), Eisai (RP), Elan (RP), Ferring (AB, AHS, BB, CW, RP, WA), Genentech (BB, RP), Glaxo-Smith Kline (RP), Janssen (AB, AHS, BH, CS, GR, LT, RK, RP, SP, UC, WA), Merck (AB, AHS, RP), Pendopharm (AHS, BB, GR), Pfizer (AB, AHS, RP), Salix (RP), Schering-Plough (RP), Shire (AB, AHS, BB, CB, CS, CW, GR, MB, RP, SM, WA), Takeda (AB, AHS, BB, CB, CS, GR, JJ, LT, RK, RP, SM, SP, UC, WA), UCB (RP), Warner Chilcott (RP). Consulting: AbbVie (DS, GR, JJ, EL, JKM, RP), Abbott (RP), Actavis (JKM), Amgen (EL, RP), Aptalis (RP), AstraZeneca (JKM, RP), Baxter (RP), Bristol-Myers Squibb (EL, RP), Celgene (EL, RP), Celltrion (JKM), Centocor (RP), Cubist (JKM, RP), CVS Caremark (EL), Eisai (RP), Elan (RP), Eli Lilly (EL), Ferring (JKM, RP), Genentech (EL), Glaxo-Smith Kline (RP), Hospira (JKM), Janssen (DS, JJ, EL, JKM, RP), Merck (RP), Mesoblast (EL), Pfizer (AHS, EL, RP), Salix (EL), Schering-Plough (RP), Seres Therapeutics (EL), Shire (JKM, RP), Sun Pharmaceuticals (EL), Takeda (DS, JJ, EL, JKM, RP), Theradig (CB, EL), Tigenix (DS), UCB (EL, RP, DS), Warner Chilcott (RP). Educational support: AbbVie (AB, RP, SP, UC), Abbott (RP), Allergan (AB), Aptalis (UC), Bristol-Myers Squibb (RP), Centocor (RP), Elan (RP), Ferring (RP), Janssen (AB, AHS, GR, RP), Millennium (RP), Pfizer (LT), Proctor and Gamble (RP), Schering-Plough (RP), Shire (LT), Takeda (AB, LT). Research grants/clinical trial funding: AbbVie (AB, AHS, BB, EL, DS, LT, RP), Abbott (RP), Alvine (BB), Amgen (AHS, BB, EL), Boehringer Ingelheim (BB), Bristol-Myers Squibb (BB, RP), Celgene (AHS, BB, EL), Centocor (RP), Elan (RP), Ferring (RP), Genentech (AHS, BB, EL), Gilead (EL), Glaxo-Smith Kline (BB), Janssen (BB, EL, RP), MedImmune (EL), Merck (BB), Millennium (AHS, RP), Pfizer (EL, LT), Proctor and Gamble (RP), Prometheus (WA), Qu Biologic (BB), Receptos (EL), RedHill Biopharm (AHS, BB), Robarts Clinical Trials (EL), Schering-Plough (RP), Seres Therapeutics (EL), Takeda (EL), UCB (EL, DS). Speaker's bureau: AbbVie (AB, AHS, BB, BH, CB, GR, JKM, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (BB, JKM), Allergan/Forest (MB), Aptalis (UC), AstraZeneca (RP), Centocor (RP), Elan (RP), Ferring (AHS, BB, JJ, JKM), Hospira (AHS, JKM), Janssen (AHS, BH, CB, CW, GR, JJ, JKM, MB, RK, RP, SP, UC, WA), Pendopharm (BH, MB), Prometheus (RP), Schering-Plough (RP), Shire (AB, AHS, BB, BH, CB, GR, JJ, JKM, MB, RP, SP), Takeda (AB, AHS, BB, CB, CW, GR, JKM, MB, RK, RP, SM, WA), Warner Chilcott (RP). Other: Qu Biologic (BB-stock options). The remaining authors disclose no conflicts. Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. Funding Information: Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. The Canadian Association of Gastroenterology thanks AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc for their generous support of the guideline process. The consensus group would like to thank the following people for their contributions: Paul Sinclair and Lesley Marshall (CAG representatives, administrative and technical support, and logistics assistance), Pauline Lavigne and Steven Portelance (unaffiliated, editorial assistance). Finally, they thank their patient advocate, Jenna Rines, for invaluable insights. Publisher Copyright: {\textcopyright} 2019 AGA Institute and the Canadian Association of Gastroenterology",

year = "2019",

month = aug,

doi = "10.1016/j.cgh.2019.02.043",

language = "English",

volume = "17",

pages = "1680--1713",

journal = "Clinical Gastroenterology and Hepatology",

issn = "1542-3565",

publisher = "W.B. Saunders Ltd",

number = "9",

}

TY - JOUR

T1 - Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease

AU - Panaccione, Remo

AU - Steinhart, A. Hillary

AU - Bressler, B.

AU - Khanna, R.

AU - Marshall, John K.

AU - Targownik, L.

AU - Afif, Waqqas

AU - Bitton, A.

AU - Borgaonkar, Mark

AU - Chauhan, Usha

AU - Halloran, Brendan

AU - Jones, Jennifer

AU - Kennedy, Erin

AU - Leontiadis, Grigorios I.

AU - Loftus, Edward V.

AU - Meddings, Jonathan

AU - Moayyedi, Paul

AU - Murthy, Sanjay

AU - Plamondon, Sophie

AU - Rosenfeld, Greg

AU - Schwartz, D.

AU - Seow, Cynthia H.

AU - Williams, Chadwick

AU - Bernstein, Charles N.

N1 - Funding Information: Funding for the consensus meeting was provided by unrestricted, arms-length grants to the CAG by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc. The CAG administered all aspects of the meeting, and the funding sources had no involvement in the process at any point, and they were not made aware of any part of the process from development of search strings and the statements to drafting and approval of these guidelines. Funding Information: Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. Conflicts of interest These authors disclose the following: Advisory board: AbbVie (AB, AHS, BB, BH, CB, CS, CW, GR, LT, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (AHS, BB, CS), Allergan (AB), Amgen (RP), Aptalis (RP), AstraZeneca (RP), Baxter (RP), Bristol-Myers Squibb (RP), Celgene (RP), Celltrion (BB), Centocor (RP), Cubist (CB, RP), Eisai (RP), Elan (RP), Ferring (AB, AHS, BB, CW, RP, WA), Genentech (BB, RP), Glaxo-Smith Kline (RP), Janssen (AB, AHS, BH, CS, GR, LT, RK, RP, SP, UC, WA), Merck (AB, AHS, RP), Pendopharm (AHS, BB, GR), Pfizer (AB, AHS, RP), Salix (RP), Schering-Plough (RP), Shire (AB, AHS, BB, CB, CS, CW, GR, MB, RP, SM, WA), Takeda (AB, AHS, BB, CB, CS, GR, JJ, LT, RK, RP, SM, SP, UC, WA), UCB (RP), Warner Chilcott (RP). Consulting: AbbVie (DS, GR, JJ, EL, JKM, RP), Abbott (RP), Actavis (JKM), Amgen (EL, RP), Aptalis (RP), AstraZeneca (JKM, RP), Baxter (RP), Bristol-Myers Squibb (EL, RP), Celgene (EL, RP), Celltrion (JKM), Centocor (RP), Cubist (JKM, RP), CVS Caremark (EL), Eisai (RP), Elan (RP), Eli Lilly (EL), Ferring (JKM, RP), Genentech (EL), Glaxo-Smith Kline (RP), Hospira (JKM), Janssen (DS, JJ, EL, JKM, RP), Merck (RP), Mesoblast (EL), Pfizer (AHS, EL, RP), Salix (EL), Schering-Plough (RP), Seres Therapeutics (EL), Shire (JKM, RP), Sun Pharmaceuticals (EL), Takeda (DS, JJ, EL, JKM, RP), Theradig (CB, EL), Tigenix (DS), UCB (EL, RP, DS), Warner Chilcott (RP). Educational support: AbbVie (AB, RP, SP, UC), Abbott (RP), Allergan (AB), Aptalis (UC), Bristol-Myers Squibb (RP), Centocor (RP), Elan (RP), Ferring (RP), Janssen (AB, AHS, GR, RP), Millennium (RP), Pfizer (LT), Proctor and Gamble (RP), Schering-Plough (RP), Shire (LT), Takeda (AB, LT). Research grants/clinical trial funding: AbbVie (AB, AHS, BB, EL, DS, LT, RP), Abbott (RP), Alvine (BB), Amgen (AHS, BB, EL), Boehringer Ingelheim (BB), Bristol-Myers Squibb (BB, RP), Celgene (AHS, BB, EL), Centocor (RP), Elan (RP), Ferring (RP), Genentech (AHS, BB, EL), Gilead (EL), Glaxo-Smith Kline (BB), Janssen (BB, EL, RP), MedImmune (EL), Merck (BB), Millennium (AHS, RP), Pfizer (EL, LT), Proctor and Gamble (RP), Prometheus (WA), Qu Biologic (BB), Receptos (EL), RedHill Biopharm (AHS, BB), Robarts Clinical Trials (EL), Schering-Plough (RP), Seres Therapeutics (EL), Takeda (EL), UCB (EL, DS). Speaker's bureau: AbbVie (AB, AHS, BB, BH, CB, GR, JKM, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (BB, JKM), Allergan/Forest (MB), Aptalis (UC), AstraZeneca (RP), Centocor (RP), Elan (RP), Ferring (AHS, BB, JJ, JKM), Hospira (AHS, JKM), Janssen (AHS, BH, CB, CW, GR, JJ, JKM, MB, RK, RP, SP, UC, WA), Pendopharm (BH, MB), Prometheus (RP), Schering-Plough (RP), Shire (AB, AHS, BB, BH, CB, GR, JJ, JKM, MB, RP, SP), Takeda (AB, AHS, BB, CB, CW, GR, JKM, MB, RK, RP, SM, WA), Warner Chilcott (RP). Other: Qu Biologic (BB-stock options). The remaining authors disclose no conflicts. Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. The Canadian Association of Gastroenterology thanks AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc for their generous support of the guideline process. The consensus group would like to thank the following people for their contributions: Paul Sinclair and Lesley Marshall (CAG representatives, administrative and technical support, and logistics assistance), Pauline Lavigne and Steven Portelance (unaffiliated, editorial assistance). Finally, they thank their patient advocate, Jenna Rines, for invaluable insights. Conflicts of interest These authors disclose the following: Advisory board: AbbVie (AB, AHS, BB, BH, CB, CS, CW, GR, LT, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (AHS, BB, CS), Allergan (AB), Amgen (RP), Aptalis (RP), AstraZeneca (RP), Baxter (RP), Bristol-Myers Squibb (RP), Celgene (RP), Celltrion (BB), Centocor (RP), Cubist (CB, RP), Eisai (RP), Elan (RP), Ferring (AB, AHS, BB, CW, RP, WA), Genentech (BB, RP), Glaxo-Smith Kline (RP), Janssen (AB, AHS, BH, CS, GR, LT, RK, RP, SP, UC, WA), Merck (AB, AHS, RP), Pendopharm (AHS, BB, GR), Pfizer (AB, AHS, RP), Salix (RP), Schering-Plough (RP), Shire (AB, AHS, BB, CB, CS, CW, GR, MB, RP, SM, WA), Takeda (AB, AHS, BB, CB, CS, GR, JJ, LT, RK, RP, SM, SP, UC, WA), UCB (RP), Warner Chilcott (RP). Consulting: AbbVie (DS, GR, JJ, EL, JKM, RP), Abbott (RP), Actavis (JKM), Amgen (EL, RP), Aptalis (RP), AstraZeneca (JKM, RP), Baxter (RP), Bristol-Myers Squibb (EL, RP), Celgene (EL, RP), Celltrion (JKM), Centocor (RP), Cubist (JKM, RP), CVS Caremark (EL), Eisai (RP), Elan (RP), Eli Lilly (EL), Ferring (JKM, RP), Genentech (EL), Glaxo-Smith Kline (RP), Hospira (JKM), Janssen (DS, JJ, EL, JKM, RP), Merck (RP), Mesoblast (EL), Pfizer (AHS, EL, RP), Salix (EL), Schering-Plough (RP), Seres Therapeutics (EL), Shire (JKM, RP), Sun Pharmaceuticals (EL), Takeda (DS, JJ, EL, JKM, RP), Theradig (CB, EL), Tigenix (DS), UCB (EL, RP, DS), Warner Chilcott (RP). Educational support: AbbVie (AB, RP, SP, UC), Abbott (RP), Allergan (AB), Aptalis (UC), Bristol-Myers Squibb (RP), Centocor (RP), Elan (RP), Ferring (RP), Janssen (AB, AHS, GR, RP), Millennium (RP), Pfizer (LT), Proctor and Gamble (RP), Schering-Plough (RP), Shire (LT), Takeda (AB, LT). Research grants/clinical trial funding: AbbVie (AB, AHS, BB, EL, DS, LT, RP), Abbott (RP), Alvine (BB), Amgen (AHS, BB, EL), Boehringer Ingelheim (BB), Bristol-Myers Squibb (BB, RP), Celgene (AHS, BB, EL), Centocor (RP), Elan (RP), Ferring (RP), Genentech (AHS, BB, EL), Gilead (EL), Glaxo-Smith Kline (BB), Janssen (BB, EL, RP), MedImmune (EL), Merck (BB), Millennium (AHS, RP), Pfizer (EL, LT), Proctor and Gamble (RP), Prometheus (WA), Qu Biologic (BB), Receptos (EL), RedHill Biopharm (AHS, BB), Robarts Clinical Trials (EL), Schering-Plough (RP), Seres Therapeutics (EL), Takeda (EL), UCB (EL, DS). Speaker's bureau: AbbVie (AB, AHS, BB, BH, CB, GR, JKM, MB, RK, RP, SM, SP, UC, WA), Abbott (RP), Actavis (BB, JKM), Allergan/Forest (MB), Aptalis (UC), AstraZeneca (RP), Centocor (RP), Elan (RP), Ferring (AHS, BB, JJ, JKM), Hospira (AHS, JKM), Janssen (AHS, BH, CB, CW, GR, JJ, JKM, MB, RK, RP, SP, UC, WA), Pendopharm (BH, MB), Prometheus (RP), Schering-Plough (RP), Shire (AB, AHS, BB, BH, CB, GR, JJ, JKM, MB, RP, SP), Takeda (AB, AHS, BB, CB, CW, GR, JKM, MB, RK, RP, SM, WA), Warner Chilcott (RP). Other: Qu Biologic (BB-stock options). The remaining authors disclose no conflicts. Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. Funding Information: Funding Supported through unrestricted grants to the Canadian Association of Gastroenterology by AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc, who had no involvement in any aspect of the guideline development. The Canadian Association of Gastroenterology thanks AbbVie Corp, Janssen Inc, Pfizer Canada Inc, and Takeda Canada Inc for their generous support of the guideline process. The consensus group would like to thank the following people for their contributions: Paul Sinclair and Lesley Marshall (CAG representatives, administrative and technical support, and logistics assistance), Pauline Lavigne and Steven Portelance (unaffiliated, editorial assistance). Finally, they thank their patient advocate, Jenna Rines, for invaluable insights. Publisher Copyright: © 2019 AGA Institute and the Canadian Association of Gastroenterology

PY - 2019/8

Y1 - 2019/8

N2 - Background & Aims: Crohn's disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. Methods: We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. Results: The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. Conclusions: Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.

AB - Background & Aims: Crohn's disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. Methods: We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. Results: The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. Conclusions: Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.

UR - http://www.scopus.com/inward/record.url?scp=85064715594&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85064715594&partnerID=8YFLogxK

U2 - 10.1016/j.cgh.2019.02.043

DO - 10.1016/j.cgh.2019.02.043

M3 - Article

C2 - 30853616

AN - SCOPUS:85064715594

SN - 1542-3565

VL - 17

SP - 1680

EP - 1713

JO - Clinical Gastroenterology and Hepatology

JF - Clinical Gastroenterology and Hepatology

IS - 9

ER -

Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease

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