title: Appropriateness of therapy for active Crohn's disease: Results of a multidisciplinary international expert panel-EPACT II.
abstract: The increasing number of trials testing management strategies for luminal Crohn's disease (CD) has not filled all the gaps in our knowledge and thus, in clinical practice, many decisions for CD patients have to be taken without the benefit of high-quality evidence.
  
  
  METHODS
  A multidisciplinary European expert panel used the RAND Appropriateness Method to develop and rate explicit criteria for the management of individual patients with active, steroid-dependent (ST-D) and steroid-refractory (ST-R) CD.
  
  
  RESULTS
  Overall, 296 indications pertaining to mild-to-moderate, severe, ST-D, and ST-R CD were rated. In anti-TNF naïve patients, budesonide and prednisone were found to be appropriate for mild-moderate CD, and infliximab (IFX) was appropriate when these had previously failed or had not been tolerated. In patients with a prior successful treatment by IFX, this drug, with or without co-administration of a thiopurine analog, was favoured. Other anti-TNFs were appropriate in the presence of intolerance or resistance to IFX. High-dose steroids, IFX or adalimumab were appropriate in severe active CD. For the 105 indications for ST-D or ST-R disease, the panel considered the thiopurine analogs, methotrexate, IFX, adalimumab, and surgery for limited resection, to be appropriate, depending on the outcome of prior therapies. Anti-TNFs were generally considered appropriate in ST-R.
  
  
  CONCLUSIONS
  Steroids, including budesonide for mild-to-moderate CD, remain the first-line therapy for active luminal CD. Anti-TNFs, in particular IFX as shown by the amount of available evidence, remain the second-line therapy for most indications. Thiopurine analogs, methotrexate and anti-TNFs are favoured in ST-D patients and ST-R patients.
authors.affiliation: Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
authors.forename: Pierre
authors.initials: P
authors.lastname: Michetti
authors.forename: Marc
authors.initials: M
authors.lastname: Stelle
authors.forename: Pascal
authors.initials: P
authors.lastname: Juillerat
authors.forename: Miquel
authors.initials: M
authors.lastname: Gassull
authors.forename: Franz Josef
authors.initials: FJ
authors.lastname: Heil
authors.forename: Eduard
authors.initials: E
authors.lastname: Stange
authors.forename: Christian
authors.initials: C
authors.lastname: Mottet
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Gonvers
authors.forename: Valérie
authors.initials: V
authors.lastname: Pittet
authors.forename: John-Paul
authors.initials: JP
authors.lastname: Vader
authors.forename: Florian
authors.initials: F
authors.lastname: Froehlich
authors.forename: Christian
authors.initials: C
authors.lastname: Felley