For those in Australia the main path that is followed is the step up approach unless you are a paediatric patient with moderate to severe refractory disease, at which point the biologics are available much earlier on.
Sarah: Was undiagnosed until the time of her surgery, therefore she had received no treatment prior to her resection and hadn't seen a GI. Her GP rang a GI that he had referred other patients with Crohn's to and with which he was impressed by their progress once reviewed. Sarah was commenced on Imuran 50mg and has remained on that ever since. The dose has never been adjusted as she has had no relapses since the surgery nearly 8 years ago.
Matt: Was diagnosed very quickly with next to no symptoms. At diagnosis he was commenced on Imuran 50mg (100mg dose was pending once the TPMT result was received. It was considered it was likely safe for him due to Sarah having no issues with it), Prednisone 40mg and Flagyl 400mg. He was to be reviewed in 6 weeks and if the GI did not see good clinical and objective markers at that point then he was going to move him onto Humira. As it was we didn't make it past 3 weeks before complications set in. Although his disease was rated as very mild to mild it only took two deep ulcers to cause no end of problems, that being fistulas and abscesses.
Surgery quickly became our only option and between hospital admissions he remained on the Imuran, which was upped to 100mg, continued with Prednisone until the course was complete and also remained on Flagyl for 6 months (3 months pre-op and 3 months post-op) and Augmentin Duo Forte for 3 months to keep the abscesses under control till surgery. Whilst I don't think this regimen made improvements to his Crohn's overall it did maintain the status quo until his resection was done. The reason for the delay in surgery was the surgeon was waiting for the inflammation to go from an acute to chronic state an thereby optimising the chances of the least amount of bowel being resected and the need for a temporary stoma would be reduced.
Since surgery he has remained on Imuran 100mg and when his old GI retired, about 12 months ago, the new guy that replaced him suggested he also take Pentasa 1grm twice daily. I questioned the effectiveness of this and whilst the GI agreed that it was a pretty useless drug for Crohn's he was able to pull up a couple of studies that showed Pentasa may be useful in post resection Ileal disease. Now the statistics are from impressive but the GI felt that given Matt's speed of onset and severity of disease that even an added 2 percent chance of keeping him in remission was worth it. Matt was happy with the maths and stated to the GI that he didn't mind taking tablets so it was a no brainer and Pentasa was added. It was also the GI that suggested we add Turmeric.
Matt has also had no relapses since his surgery 3 years ago.
The impression I received from the original GI was he was not prepared to sit around and wait for things for happen. The new guy, although having some different ideas, is also very pro active and I get the feeling with him too that he would change treatment in a heart beat if he felt there was not an adequate response in a very defined time frame.
I agree with what others have said...I wish it was easier and more defined for you. :ghug:
Dusty. xxx
After six weeks on exclusive EN, they moved him to supplemental EN (1/2 dose) as maintenance and he was on that until his transfer to adult GI a bit over a year later. Although MREs did show continued inflammation, his ped GI didn't seem to be in a rush to add anything more - he'd comment that 'we'll consider metho after results' but always seemed happy with S's progress and all results. To be honest, I think part of his reasoning was that he knew S was going to be transferred soon and, as S was stable and in clinical remission, perhaps he was hesitant to commence a new treatment knowing another GI would be taking over in the near future??? 
