Previous changes

December 2023 — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.

August 2020 — minor update. Broken URL link updated and typographical error corrected.

April 2020 — minor update. New management scenario created to provide information regarding COVID-19.

May 2019 — minor update. Information from the updated National Institute for Health and Care Excellence (NICE) clinical guidelines Crohn's disease. Management in adults, children and young people (full NICE guideline) and Crohn's disease: management have been added to the topic. No major changes to recommendations have been made.

August to September 2017 — reviewed. A literature search was conducted in July 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone significant restructuring. The recommendations on the diagnosis and management of confirmed Crohn's disease have been amended in line with current evidence. The sections on specialist investigations and management have been updated and expanded. The Prescribing information section has been deleted and links made to other relevant CKS topics.

December 2016 — minor update. The section on adverse effects of corticosteroids has been updated in line with the manufacturer's Summary of Product Characteristics. Myocardial ischaemia or infarction and arrhythmia have been added as possible adverse effects of infliximab in line with the manufacturer's Summary of Product Characteristics.

November 2016 — minor update. Adverse effects of loperamide have been updated in line with the Food and Drug Administration (FDA) drug safety communication, warning that exceeding the maximum dose can cause serious cardiac problems including QT interval prolongation, Torsades de pointes or other ventricular arrhythmias, syncope, and cardiac arrest.

September 2016 — minor update. The brand name Octasa^® has been added to the Prescribing information section as another licensed and available preparation of mesalazine, in line with the British National Formulary.

April 2015 — minor update. Text updated to reflect a new law on drugs and impaired driving, in line with the Department for Transport Guidance for health professionals on drug driving.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

December 2012 — reviewed. A literature search was conducted in November 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. No major changes to clinical recommendations have been made.

August 2012 — text in the Prescribing Information section has been updated to clarify recommendations for the use of oral hormonal contraception while taking metronidazole or ciprofloxacin.

June 2011 — minor update to the text to reflect guidance issued by the British Society of Gastroenterology. The 2010/2011 QIPP options for local implementation have been added to this topic. The National Institute for Health and Care Excellence (NICE) have issued guidance on colonoscopic surveillance of people with Crohn's disease. 

February to June 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 May 2024.

HTAs (Health Technology Assessments)

• NICE (2025) Mirikizumab for previously treated moderately to severely active Crohn's disease. National Institute for Health and Care Excellence. https://www.nice.org.uk/ [Free Full-text]
• NICE (2025) Guselkumab for previously treated moderately to severely active Crohn's disease. National Institute for Health and Care Excellence. https://www.nice.org.uk/ [Free Full-text]

Economic Appraisals

No new economic appraisals relevant to England since 1 May 2024.

Systematic reviews and meta-analyses

No new Systematic reviews and meta-analyses since 1 May 2024.

Primary evidence

• Peyrin-Biroulet, L., Chapman, C., Colombel, J., et al. (2024) Risankizumab versus Ustekinumab for Moderate-to-Severe Crohn’s Disease. New England Journal of Medicine. https://www.nejm.org/ [Abstract]
• Lund, K., Ryg, J., Knudsen, T., Kjeldsen, J., et al. (2025). The prevalence of polypharmacy increases with age among patients with inflammatory bowel disease: A nationwide cohort study. British Journal of Clinical Pharmacology. [Abstract]

New policies

No new national policies or guidelines since 1 May 2024. 

New safety alerts

No new safety alerts since 1 May 2024. 

Changes in product availability

• New product Yuflyma 20 mg solution is indicated for the treatment of moderately to severely active Crohn's disease in paediatric patients (from 6 years of age) who have had an inadequate response to conventional therapy including primary nutrition therapy and a corticosteroid and/or an immunomodulator, or who are intolerant to or have contraindications for such therapies. See more here.
• New product Uzpruvo 45 mg solution is indicated for the treatment of adult patients with moderately to severely active Crohn's disease who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a TNFα antagonist or have medical contraindications to such therapies. See more here.
• New product Amgevita HCF (adalimumab) 40 mg solution for injection in pre-filled pen and 20mg and 40mg in pre-filled syringe. Biosimilar licensed for treatment of rheumatoid arthritis, juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, hidradenitis suppurativa, psoriasis, Crohn's disease, ulcerative colitis, and uveitis. See more here.
• Skyrizi (risankizumab) 180 mg solution for injection in cartridge. This is a new strength and presentation of risankizumab, a monoclonal antibody that blocks IL-23 antagonist, licensed for treatment of Crohn's disease and ulcerative colitis. Product range for this indication also includes 360mg cartridge, and 600mg infusion. See more here.
• New product Imraldi 40 mg solution for injection is indicated for treatment of moderately to severely active Crohn's disease, in adult patients who have not responded despite a full and adequate course of therapy with a corticosteroid and/or an immunosuppressant; or who are intolerant to or have medical contraindications for such therapies. See more here. 
• New product Steqeyma (ustekinumab) 45 mg solution for injection in pre-filled syringe. This biosimilar is licenced for the treatment of plaque psoriasis, paediatric plaque psoriasis, psoriatic arthritis and Crohn’s disease. Unlike the originator product, Stelara, it is not licensed for the treatment of ulcerative colitis. See more here.
• New product Otulfi (ustekinumab) 130 mg concentrate for solution for infusion. This biosimilar to the reference product Stelara, is licensed for treatment of Crohn's Disease and ulcerative colitis. See more here.
• New product Otulfi (ustekinumab) 45 mg and 90 mg solution for injection in pre-filled syringe. This biosimilar to the reference product Stelara, is licensed for treatment of plaque psoriasis, paediatric plaque psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis. See more here.
• New product Omvoh (mirikizumab) 100 + 200 mg Solution for injection in pre-filled pen. New strength (200mg) used in addition to existing 100mg pen, licensed for treatment of adults with moderately to severely active Crohn's disease who have had inadequate response with, lost response to, or were intolerant to either conventional therapy or a biologic treatment. See more here.
• New product WEZENLA is indicated for the treatment of adult patients with moderately to severely active Crohn's disease who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a TNFα antagonist or have medical contraindications to such therapies. See more here.
• New product Tremfya (guselkumab) 200 mg concentrate for solution for infusion. This is a new presentation of the IL-23 inhibitor, licensed for treatment of adult patients with moderately to severely active Crohn's disease or Ulcerative Colitis. Tremfya is also available as 100mg pre-filled pens and 200mg PushPen pre-filled pen device. See more here.
• New product Tremfya (guselkumab) 100 mg PushPen solution for injection in pre-filled pen, is licensed for the treatment of Crohn's disease. See more here.
• New product Otulfi (ustekinumab) 45 mg Solution for injection is a new presentation of Otulfi in a vial, licensed for subcutaneous administration, to treat adult and paediatric Crohn's disease. See more here.
• New product Remsima (infliximab) 40mg/1ml concentrate for Solution for infusion vial. This new formulation is licensed for the treatment of rheumatoid arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis, psoriasis and psoriatic arthritis. It contains sorbitol and is contra-indicated in patients with hereditary fructose intolerance. See more here.

Basis for recommendation

The recommendations on when to suspect Crohn's disease are based on the European Crohn's and Colitis Organisation (ECCO) publication 3rd European evidence-based consensus on the diagnosis and management of Crohn's disease 2016. Part 1: Diagnosis and medical management [Gomollon, 2017] and Part 2: Surgical management and special situations [Gionchetti, 2017], the British Society of Gastroenterology (BSG) Guidelines for the management of inflammatory bowel disease in adults [Lamb, 2019], the ECCO-ESPGHAN Guideline update The medical management of paediatric Crohn's disease [van Rheenan, 2021], and expert opinion in review articles on Crohn's disease [BMJ Best Practice, 2023; Ranasinghe, 2024] and inflammatory bowel disease in children [Oliveira, 2017; Mitchel, 2024].

• Abdominal pain and weight loss are seen in about 80% and 60% of people with Crohn's disease, respectively, before diagnosis, and blood and/or mucus in the stool may be seen in up to 40–50% of people with Crohn's colitis [Gomollon, 2017].
• The ESPGHAN guideline states that only 25% of children present with the classic triad of diarrhoea, abdominal pain, and weight loss [van Rheenan, 2021].
• Perianal disease may precede or appear simultaneously with intestinal symptoms [Gionchetti, 2017], and extra-intestinal manifestations may be the initial presentation of Crohn's disease [Oliveira, 2017].

Basis for recommendation

The recommendations on investigations in primary care are largely based on the National Institute for Health and Care Excellence (NICE) diagnostic guidance Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel [NICE, 2013], the European Crohn's and Colitis Organisation (ECCO) publications 3rd European evidence-based consensus on the diagnosis and management of Crohn's disease 2016. Part 1: Diagnosis and medical management [Gomollon, 2017], European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases [Dignass, 2015], the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Revised Porto Criteria for the diagnosis of inflammatory bowel disease in children and adolescents [Levine, 2014], the British Society of Gastroenterology (BSG) Guidelines for the management of inflammatory bowel disease in adults [Lamb, 2019], consensus Guidelines of ECCO/ESPGHAN the medical management of paediatric Crohn's disease [van Rheenan, 2021], and expert opinion in review articles on Crohn's disease [BMJ Best Practice, 2023; Mitchel, 2024] and inflammatory bowel disease in children [Oliveira, 2017].

• About two-thirds of people with inflammatory bowel disease have anaemia at diagnosis [Dignass, 2015].
• Faecal calprotectin testing for colonic inflammation may be considered to help distinguish between inflammatory bowel disease and irritable bowel syndrome in adults with recent-onset lower gastrointestinal symptoms for whom specialist assessment is being considered [NICE, 2013]. Faecal calprotectin has a greater than 90% positive predictive value for endoscopically active Crohn's disease [Gomollon, 2017].
• Expert opinion in a review article is that investigation results may be normal in a person with active Crohn's disease [BMJ Best Practice, 2023].

Basis for recommendation

This information is based on the European Crohn's and Colitis Organisation (ECCO) publication 3rd European evidence-based consensus on the diagnosis and management of Crohn's disease 2016. Part 1: Diagnosis and medical management [Gomollon, 2017], and expert opinion in a review article on Crohn's disease [BMJ Best Practice, 2023].

Management of suspected Crohn's disease

• If Crohn's disease is suspected:
  • Arrange emergency hospital admission if the person is systemically unwell with symptoms of bloody diarrhoea, fever, tachycardia, or hypotension.
  • If hospital admission is not indicated, arrange an urgent referral to secondary care (paediatric gastroenterologist for children or gastroenterologist for adults) for confirmation of the diagnosis and initiation of specialist drug treatments.
    • Do not prescribe anti-diarrhoeal drugs if the clinical diagnosis is uncertain, as they may precipitate toxic megacolon in people with ulcerative colitis.
  • If there are suspected extra-intestinal manifestations that cannot be managed in primary care, arrange referral to an appropriate specialist (such as rheumatology, dermatology, or ophthalmology).
• Following confirmation of the diagnosis in secondary care, arrange to review the person regularly in primary care.
  • The frequency of the review will depend on clinical judgement and the frequency of specialist gastroenterology follow up.

How should I review a person with confirmed Crohn's disease in primary care?

• Assess the impact of symptoms on daily functioning, such as home, work, school, and leisure activities, and assess for associated anxiety and/or depression. See the CKS topics on Generalized anxiety disorder, Depression in children, and Depression for more information.
• Provide advice on Crohn's disease and offer sources of information and support:
  • Explain that Crohn's disease is a lifelong condition, which may have unpredictable relapses and remissions, specialist drug treatments aim to induce remission of the disease and to treat symptoms, and occasionally surgical treatments may be necessary.
  • Crohn's and Colitis UK is a national charity that provides support for people with Crohn's disease and their families (website and live chat available at www.crohnsandcolitis.org.uk; telephone information service 0300 2225700). It publishes a range of information sheets and booklets including Crohn's disease and IBD in children: a parent's guide, and provides information on managing symptoms, drug treatments, diet, pregnancy, education, employment, and travel.
  • Emotional support is available through the Samaritans helpline (116123 - 24 hrs a day, 7 days a week).
  • CICRA (Crohn's in Childhood Research Association) is a national charity that supports children and young people with inflammatory bowel disease (website available at www.cicra.org), which provides patient information and young people's forums for peer support.
• Encourage the person to stop smoking, if needed and appropriate, as this may reduce the risk of relapse. See the CKS topic on Smoking cessation for more information.
  • The Crohn's and Colitis UK patient information sheet Smoking and IBD has some useful information.
• Assess the person's risk of osteoporosis, including dietary calcium intake, the extent of Crohn's disease, and history of small bowel resection, and manage appropriately. See the CKS topic on Osteoporosis - prevention of fragility fractures for more information.
  • The Crohn's and Colitis UK patient information sheet Bones and IBD has some useful information.
• Ensure that the person has follow-up arranged with a gastroenterology specialist, if needed, and encourage the person to attend appointments regularly.
  • Ensure the person is aware of the need for colorectal cancer surveillance and has colonoscopy screening arranged by the specialist team if symptoms started 10 years ago and there is Crohn's colitis affecting more than one segment of colon. The frequency of subsequent monitoring is a specialist decision, depending on the severity and duration of colitis, presence of co-morbid conditions, and the appearances at colonoscopy.
  • The Crohn's and Colitis UK patient information sheet Bowel cancer and IBD has some useful information.
• If a shared-care agreement is in place, prescribe and monitor specialist drug treatments, if appropriate, and encourage the person to take their medication regularly as prescribed.
  • Monitoring may include checking serum ferritin, vitamin B₁₂, folate, calcium, and vitamin D levels, and arranging supplementation where appropriate. See the CKS topics on Anaemia - iron deficiency, Anaemia - B12 and folate deficiency, Vitamin D deficiency in adults - treatment and prevention, and Vitamin D deficiency in children for more information.
  • Note that specialist drug treatments for the induction and maintenance of remission in Crohn's disease should always be initiated by a specialist. If there are any uncertainties regarding adverse effects or safety of drug treatments, seek specialist advice.
• Assess for clinical features suggesting a Crohn's disease flare-up or other troublesome symptoms, and manage appropriately. Consider checking:
  • The person's body mass index (BMI), and for unintended weight loss or signs of malnutrition.
  • The serum C-reactive protein (CRP) level if a flare-up is suspected, as an increased level may indicate a severe relapse requiring hospital admission. See the section on How should I manage a person with a Crohn's disease flare-up? for more information.
• Arrange a referral to an appropriate specialist (such as rheumatology, dermatology, or ophthalmology) if appropriate, if there are suspected extra-intestinal manifestations.
• If the person is taking immunosuppressive or biologic therapy, ensure they are aware that:
  • Live vaccines are contraindicated, and these vaccines should only be given before the start of specialist treatment, or else postponed for at least 6 months after stopping this therapy.
  • They are at increased risk of influenza and pneumococcal infection and should receive appropriate vaccinations regularly. See the CKS topics on Immunizations - seasonal influenza and Immunizations - pneumococcal for more information.

How should I manage a person with a Crohn's disease flare-up?

• Arrange an emergency hospital admission if the person has a suspected flare-up of Crohn's disease and is systemically unwell with severe symptoms, such as:
  • Severe diarrhoea (more than 6–8 stools a day).
  • Fever, dehydration, tachycardia, or hypotension.
  • Suspected intestinal obstruction or intra-abdominal or perianal abscess.
  • Cachexia with body mass index (BMI) less than 18.5 kg/m², or unintended sudden weight loss.
  • Persistent symptoms despite optimal management in primary care.
    • Note that a raised serum C-reactive protein (CRP) level may be suggestive of a severe disease flare-up.
• If admission to hospital is not indicated:
  • Consider whether symptoms may be due to an alternative diagnosis, and manage appropriately.
  • Check the person's adherence to their current drug treatment regimen, and encourage them to take medication regularly and appropriately.
  • Consider arranging an urgent specialist gastroenterology review appointment or seeking specialist advice.
    • Consider prescribing drug treatment for disease flare-ups according to the person's shared-care agreement, such as starting a tapered course of oral corticosteroids, if appropriate, whilst awaiting specialist review. Note: corticosteroids should not be started in people taking dual immunosuppressive or biologic therapy, and corticosteroids should not be used to maintain disease remission.
  • Consider arranging a referral to a dietitian if there are signs of unintended weight loss or malnutrition.
• If there are recurrent flares of disease activity, seek specialist advice regarding whether the person's maintenance treatment regimen needs to be changed or whether surgery may be needed.

How should I manage symptoms in people with Crohn's disease?

If there are troublesome symptoms associated with Crohn's disease, ensure that the person's maintenance treatment is optimal and seek specialist advice if necessary. The following management strategies may be appropriate in primary care or according to the person's shared-care agreement (if available).

• Diarrhoea
  • Exclude any alternative cause for diarrhoea symptoms, such as infection, abscess formation, dysmotility, bacterial overgrowth, bile salt malabsorption, or drugs, and manage appropriately.
    • Suspect a diagnosis of bile salt malabsorption if there is watery diarrhoea accompanied by abdominal bloating and steatorrhoea (suggested by pale, floating stool), particularly if the person has extensive ileal disease or a history of distal ileal resection.
    • Diarrhoea may be secondary to drug treatment, such as laxatives, iron supplements, azathioprine, mercaptopurine, or methotrexate. Seek specialist advice regarding reducing or stopping medication, if necessary.
  • If diarrhoea symptoms persist, consider whether symptomatic treatment is appropriate, following specialist advice if necessary. Options include:
    • Anti-motility drugs which slow colonic transit (for example loperamide). See the CKS topic on Irritable bowel syndrome for more information.
    • Anti-spasmodic drugs for pain relief (for example mebeverine). See the CKS topic on Irritable bowel syndrome for more information.
    • Bulk-forming laxatives (for example ispaghula husk). See the CKS topics on Constipation and Constipation in children for more information.
    • A bile acid sequestrant (such as colestyramine) to bind bile salts, if a specialist diagnosis of bile acid malabsorption has been made and drug treatment has been previously prescribed by a specialist. If this is a new presentation or a bile acid sequestrant has not previously been prescribed, seek specialist advice.
    • Note: do not prescribe symptomatic treatment for people who are systemically unwell, have abdominal tenderness or signs of intestinal obstruction.
  • Offer sources of information to help manage symptoms, such as the Crohn's and Colitis UK patient information sheets Diarrhoea, constipation, Managing bowel incontinence in IBD, and Managing bloating and wind.
• Fistulae and strictures
  • If a fistula or intestinal stricture is suspected:
    • Arrange hospital admission, arrange a referral to colorectal surgery, or seek specialist advice, depending on clinical judgement. Specialist treatment depends on the location, scale, and nature of symptoms.
  • Asymptomatic simple perianal fistulae may not need any specific treatment.
  • Specialist drug treatment of a fistula may be with long-term antibiotics (such as metronidazole or ciprofloxacin) to control infection.
  • Fistulae and strictures may be treated with immunosuppressive drugs to control inflammation.
  • Surgery may be indicated for intra-abdominal abscesses, complicated perianal or internal fistulae that fail to respond to optimal medical treatment, strictures with symptoms of partial or complete bowel obstruction, or in cases of severe infection.
    • An endoscopic procedure or surgery may be needed to dilate or excise an intestinal stricture.
  • Offer sources of information, such as the Crohn's and Colitis UK patient information sheets Living with a fistula and Surgery for Crohn's disease.
• Upper gastrointestinal symptoms
  • If the person has previously been investigated for upper gastrointestinal symptoms, manage the underlying cause appropriately. See the CKS topics on Dyspepsia - proven GORD , Dyspepsia - proven peptic ulcer, Dyspepsia - proven functional, and Dyspepsia - pregnancy-associated for more information.
  • Assess for any alarm symptoms that may suggest serious underlying pathology, and manage appropriately. See the CKS topic on Gastrointestinal tract (upper) cancers - recognition and referral for more information.
  • For other people, consider whether Crohn's disease may be affecting the stomach or duodenum, and manage appropriately. See the CKS topic on Dyspepsia - unidentified cause for more information.
  • Consider checking serum full blood count and C-reactive protein (CRP) to assess for anaemia and disease activity.
• Abdominal or perianal pain
  • Identify the underlying cause for abdominal or perianal pain, wherever possible, to allow appropriate management.
    • Persistent severe pain may indicate poor disease control or complications, such as pending perforation.
    • If a person has Crohn's disease with suspected perianal sepsis or fistula, arrange urgent hospital admission for examination under anaesthesia to consider whether surgical drainage is needed.
  • Offer analgesia to help relieve symptoms.
    • Consider paracetamol first-line. Opiates may be needed for additional symptom relief. See the CKS topic on Analgesia - mild-to-moderate pain for more information.
    • Advise the person to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) wherever possible, as they may aggravate Crohn's disease.
  • If pain is not effectively controlled with optimal analgesia in primary care, consider arranging referral to a chronic pain service, for specialist management.
• Fatigue
  • Exclude any alternative or contributing cause for persistent fatigue (such as pain, anaemia, reduced nutritional intake and activity levels, sleep disturbance, stress, anxiety, or depression), and manage appropriately. See the CKS topics on Tiredness/fatigue in adults, Insomnia, Generalized anxiety disorder, Depression, and Depression in children for more information.
    • Consider checking serum full blood count, ferritin, vitamin B₁₂ and folate levels, as people with Crohn's disease can develop iron deficiency anaemia due to blood loss or decreased absorption; anaemia of chronic disease; anaemia secondary to nutritional deficiencies; or drug-induced anaemia secondary to mercaptopurine, azathioprine, or sulfasalazine, for example. See the CKS topics on Anaemia - iron deficiency and Anaemia - B12 and folate deficiency for more information.
    • Be aware that the optimal management of anaemia of chronic disease involves induction of remission of Crohn's disease.
  • Offer sources of information, such as the Crohn's and Colitis UK patient information sheet Fatigue and IBD.
• Oral problems
  • If the person develops suspected oral lesions secondary to Crohn's disease (such as mucosal tags, 'cobblestoning' [close-packed mucosal nodules], aphthous ulcers, or angular cheilitis), arrange a gastroenterology clinic review appointment and/or referral to a specialist in oral medicine, depending on clinical judgement.
    • Specialist treatments may include topical or intra-lesional corticosteroids, topical or systemic immunosuppressives or biologic agents, and enteral nutritional support.
    • See the CKS topic on Aphthous ulcer for more information.

What should I advise a person with Crohn's disease about fertility issues?

• Contraception advice
  • For women with Crohn's disease, the choice of contraceptive method may be influenced by factors such as malabsorption, surgical history, prolonged immobility, extra-intestinal manifestations (such as primary sclerosing cholangitis), and associated conditions (such as osteoporosis and venous thromboembolism).
    • See the CKS topic on Contraception - assessment for detailed information on contraception options for women with different co-morbidities.
    • The College of Sexual and Reproductive Healthcare (CoSRH) UK Medical Eligibility Criteria for contraceptive use has detailed information on prescribing contraception for women with inflammatory bowel disease (IBD).
    • Note that:
      • The efficacy of oral contraception may be reduced in women with malabsorption, small bowel disease, or a history of small bowel resection. Oral methods are unaffected by colectomy and ileostomy.
      • Effective contraception should be prescribed during treatment and for at least 3 months after treatment with methotrexate (in men and women), for at least 6 months after stopping infliximab, and for at least 5 months after stopping adalimumab.
  • Offer sources of support and information, such as the Crohn's and Colitis UK patient information leaflet Sexual relationships and IBD.
• Fertility advice
  • Advise women with Crohn's disease that:
    • Active disease may reduce fertility rates, and inactive disease should not affect fertility.
    • Women who have abdominal or pelvic sepsis, surgery or adhesions may be at increased risk of impaired tubal function.
    • Drug treatment with methotrexate may affect oogenesis and fertility.
    • See the CKS topic on Infertility for more information.
  • Advise men with Crohn's disease that:
    • Fertility is unlikely to be affected for most men with Crohn's disease, but pelvic surgery may lead to erectile dysfunction or ejaculatory problems. See the CKS topic on Erectile dysfunction for more information.
    • Drug treatment with sulfasalazine or methotrexate may affect spermatogenesis, however, the effect should be reversible on stopping treatment. Infliximab may affect semen quality by reducing motility in some men.
  • Offer sources of support and information, such as the Crohn's and Colitis UK patient information leaflet Reproductive health and IBD.
• Pre-pregnancy planning
  • Refer women and men to a gastroenterologist for pre-pregnancy counselling before trying to conceive, if they are planning a pregnancy. See the CKS topic on Pre-conception - advice and management for more information.
    • For women, specialist drug treatment may need to be changed as some medications are teratogenic. Crohn's disease management should be optimized by the specialist, to ensure that the disease is well controlled and the person is in remission before trying to conceive. This reduces the risk of persistent disease activity and relapse during pregnancy.
    • For men, drug treatments that affect spermatogenesis may need to be changed to a different drug or temporarily stopped, following specialist assessment.

What advice should I give a pregnant or breastfeeding woman with Crohn's disease?

Advise women and men they need to be referred to a gastroenterologist before trying to conceive if they are planning a pregnancy. See the CKS topic on Pre-conception - advice and management for more information.

• Pregnancy advice
  • If a woman has a planned pregnancy, ensure she is managed jointly by a gastroenterologist and obstetrician with appropriate expertise.
  • If a woman has an unplanned pregnancy and is prescribed:
    • Methotrexate, infliximab, or adalimumab, seek immediate specialist advice from a gastroenterologist and/or a specialist in fetal medicine about stopping and changing treatment and starting folic acid supplementation.
    • Other medication, advise the woman to continue maintenance drug treatment, start folic acid supplementation, and arrange an urgent specialist gastroenterology review appointment to ensure that management of Crohn's disease is optimized.
  • If a woman has had significant pelvic surgery, extensive perianal disease, or active rectal involvement, she may be offered elective caesarean section to reduce the risk of potential anal sphincter damage.
  • Offer sources of support and information, such as the Crohn's and Colitis UK patient information leaflet Pregnancy and IBD.
• Breastfeeding advice
  • If a woman with Crohn's disease wishes to breastfeed, seek specialist gastroenterology advice if there is any uncertainty about the safety of breastfeeding while prescribed specialist medication.
    • Some drug treatments such as methotrexate, adalimumab, loperamide, ciprofloxacin, and high-dose metronidazole may need to be stopped while breastfeeding, and alternative medication started by a specialist if needed.
  • If a woman experiences problems breastfeeding, see the CKS topics on Breastfeeding problems and Mastitis and breast abscess for more information.