What is first-line and what is second-line therapy in adult patients with moderate to severe Crohn’s disease?

Crohn's disease, a chronic inflammatory bowel disease, necessitates a comprehensive treatment approach tailored to the individual's specific disease characteristics and overall health. Treatment strategies aim to induce and maintain remission, alleviate symptoms, normalize biomarkers, improve the endoscopic appearance of the intestine, and improve quality of life. Key therapeutic options include pharmacotherapy, featuring corticosteroids, immunomodulators, monoclonal antibodies, and more recently Janus Kinase inhibitors (JAKi) which target different mechanisms of inflammation. Additionally, surgical interventions may be required for complications or when medical therapy fails. The recent introduction of novel therapies, such as the interleukin-23 (IL-23) anti-p19 inhibitor risankizumab and the selective JAKi upadacitinib, raises pertinent questions regarding the optimal sequencing of advanced therapeutic options. This review evaluates current data to address these questions and reflects the author's perspectives based on a presentation at the 27th Annual University of Manitoba Key Topics in Gastroenterology 2024.