Version July 2025
This algorithm depicts a range of reasonable practice for pediatric patients who did not respond or lost response to anti-TNF medication. For these treatment options, most evidence is from studies in adults with CD and small open-label case series in children. Treatment decisions for individual patients typically depend on a variety of factors, including patient and family preference, response to prior regimens, cost considerations, clinician experience with a particular approach, and drug availability (refer to inset). Remission is usually assessed after 3 to 6 months of therapy.
Remission is generally defined as a composite endpoint including clinical remission of symptoms, normalization of relevant laboratory values, and endoscopic remission. In patients with mid-small bowel disease, remission is assessed by MRI and capsule endoscopy.
CD: Crohn disease; EEN: exclusive enteral nutrition; IBD: inflammatory bowel disease; IL-23: interleukin 23; JIA: juvenile idiopathic arthritis; MRI: magnetic resonance imaging; TNF: tumor necrosis factor.
* Anti-TNF medications include infliximab, adalimumab, and biosimilars. For details about therapeutic drug monitoring, refer to UpToDate content on medical therapies for CD in children.
¶ For reinduction, either EEN or glucocorticoids are often effective and the choice between these requires shared decision-making with the family. EEN is commonly used in Europe and is appealing to those who wish to avoid glucocorticoid side effects.
Δ For the subset of patients with prior nonresponse to both vedolizumab and anti-IL-23 medication, upadacitinib is the preferred next step.
◊ Upadacitinib has rapid onset of action, usually within 1 to 2 months. It is taken orally, and a liquid form is available. This is an off-label use in pediatrics and dosing is not well established.
