NICE NG129 2019: Crohn's disease management guideline essentials

Who it applies to

Adults, children and young people with Crohn's disease being managed in primary and secondary care, including those being considered for surgery.

Key recommendations

• Monotherapy with a conventional glucocorticoid (prednisolone, methylprednisolone or intravenous hydrocortisone) is recommended to induce remission in a first presentation or single inflammatory exacerbation in a 12-month period.
• Budesonide can be considered as an alternative to conventional steroids when a milder side-effect profile is a priority, though it is generally less effective.
• 5-aminosalicylates (e.g. mesalazine) should only be considered for inducing remission if glucocorticoids and budesonide are unsuitable or declined, as they are less effective overall.
• Azathioprine or mercaptopurine can be added to a glucocorticoid or budesonide if there are two or more inflammatory exacerbations in a 12-month period, or if the steroid dose cannot be tapered; thiopurine methyltransferase (TPMT) activity should be checked before starting thiopurines.
• Methotrexate is an option for inducing remission when thiopurines are not tolerated or are contraindicated, used as add-on therapy alongside a glucocorticoid or budesonide.
• Biological therapies (such as infliximab or adalimumab) are recommended for severe, active Crohn's disease that has not responded to or is intolerant of conventional therapy, in line with relevant NICE technology appraisals.
• For maintenance of remission, azathioprine or mercaptopurine monotherapy is preferred over no treatment or 5-ASA monotherapy, with TPMT testing guiding safe dosing.
• Methotrexate monotherapy for maintenance should be considered only if methotrexate was needed to induce remission or if the patient could not tolerate azathioprine/mercaptopurine.
• Routine maintenance treatment is not recommended after surgically induced remission unless there are risk factors for relapse, in which case azathioprine (with or without a short course of metronidazole) may be offered.
• Smoking cessation advice should be given to all patients with Crohn's disease because continued smoking worsens disease course and increases relapse risk.
• Surgery should be discussed as an alternative to medical treatment early on for people with limited, isolated ileocaecal disease, comparing risks and benefits of each approach.

Practice points for students

• Glucocorticoids remain first-line for inducing remission in a first flare, not biologics or immunomodulators.
• Check TPMT activity before starting azathioprine or mercaptopurine to reduce risk of myelosuppression.
• 5-ASAs are a fallback option for induction, not a preferred first-line choice, reflecting weaker evidence in Crohn's compared with ulcerative colitis.
• Isolated ileocaecal disease is a scenario where surgery should be actively discussed as a reasonable alternative to drug therapy.
• Smoking cessation is a key modifiable factor affecting disease relapse and should be addressed at every opportunity.

Condition

Other guidelines on this topic

• ACG Clinical Guideline: Management of Crohn's Disease in AdultsACG2025Official guideline
• AGA Living Clinical Practice Guideline on the Pharmacologic Management of Moderate-to-Severe Crohn's DiseaseAGA2025Official guideline

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.