## First-Line Induction Therapy in Active Crohn Disease **Key Point:** Corticosteroids (typically prednisolone 0.5–1 mg/kg/day or equivalent) are the gold standard for induction of remission in moderate-to-severe active Crohn disease when aminosalicylates have failed. ### Rationale for Corticosteroids **High-Yield:** Corticosteroids provide rapid anti-inflammatory effect and are superior to aminosalicylates for induction but are NOT suitable for maintenance due to side effects. **Clinical Pearl:** In Crohn disease (unlike UC), aminosalicylates are less effective; corticosteroids remain first-line for active disease induction across all segments of the GI tract. ### Role of Other Agents | Agent | Role | Timing | |-------|------|--------| | **Corticosteroids** | Induction of remission | First-line for active disease | | **Infliximab** | Severe/fistulizing disease, steroid-refractory | Second-line or in specific phenotypes | | **Azathioprine** | Maintenance of remission | Not for acute induction | | **Methotrexate** | Steroid-sparing maintenance | Not for acute induction | **Warning:** Corticosteroids should NOT be used for maintenance therapy due to cumulative toxicity (osteoporosis, infection, metabolic effects). They are bridging agents only. ### Mechanism Corticosteroids inhibit NF-κB signaling and reduce pro-inflammatory cytokine production (TNF-α, IL-6, IL-8), providing rapid control of mucosal inflammation in active Crohn disease. **Mnemonic:** **CRAM** — Corticosteroids for Remission, Azathioprine/Maintenance, Monoclonal (anti-TNF) for severe. [cite:Harrison 21e Ch 297]
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