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spam essay 22,23,26,27 adalimumab or certolizumab may be used in patients with pfizer viagra free inadequate response to infliximab. 22,23,26,27 anti tnf-α agents may be combined with azathioprine for enhanced efficacy. 26,27 this combination is superior to either agent alone. Natalizumab or vedolizumab may be used for patients failing oral therapies and anti-tnf-α agents. 29,31 for patients with perianal fistulae, antibiotics (metronidazole or ciprofloxacin), infliximab, adalimumab, and certolizumab are appropriate treatment options. Complex perianal fistulae may require surgical intervention but may also be amenable to treatment with antibiotics, azathioprine, 6-mp, or antitnf-α agents. 15,22,26,27 »» severe to fulminant active cd most patients with severe to fulminant cd require hospitalization for appropriate treatment. Patients should be assessed for possible surgical intervention if abdominal distention, masses, abscess, or obstruction are present. Daily iv doses of corticosteroids equivalent to prednisone 40 to 60 mg are recommended as initial therapy to rapidly suppress severe inflammation. Although infliximab, adalimumab, or certolizumab may be used in severe active cd, there is no evidence that these agents are effective for fulminant disease. Natalizumab or vedolizumab can be used for severe cd but are reserved for patients failing other available therapies, including tnf-α inhibitors. Adjunctive therapy with fluid and electrolyte replacement should be initiated. Nutritional support with enteral or parenteral nutrition may be indicated for patients unable to eat for more than 5 to 7 days. 2 some evidence suggests that enteral nutrition provides anti-inflammatory effects in patients with active cd. 39,40,41 limited evidence indicates that cyclosporine, or possibly tacrolimus, may be effective as salvage therapy for patients who fail iv corticosteroid therapy. 2,3,22 surgical intervention may ultimately be necessary for medically refractory disease. »» maintenance of remission in cd patients with cd are at high risk for disease relapse after induction of remission. Within 2 years, up to 80% of patients experience a relapse. Therefore, many patients require indefinite maintenance therapy. Maintenance of remission of cd may be achieved with immunosuppressants (azathioprine, 6-mp, or methotrexate), biologic agents (infliximab, adalimumab, certolizumab pegol, natalizumab, or vedolizumab), and less frequently with oral or topical aminosalicylate derivatives. In contrast to their use in uc, sulfasalazine and the newer aminosalicylates are marginally effective in preventing cd relapse in patients with medically induced remission, with success rates of only 10% to 20% at 1 year. 3,39 despite not being recommended as first-line therapy, aminosalicylates are routinely used to attempt maintenance of remission of cd. Some evidence suggests that aminosalicylates may prevent or delay disease recurrence in patients with surgically induced remisson.

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