101
|
Lee J, Allen R, Ashley S, Becker S, Cummins P, Gbadamosi A, Gooding O, Huston J, Le Couteur J, O'Sullivan D, Wilson S, Lomer MCE. British Dietetic Association evidence-based guidelines for the dietary management of Crohn's disease in adults. J Hum Nutr Diet 2013; 27:207-18. [PMID: 24313460 DOI: 10.1111/jhn.12176] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease is a debilitating chronic inflammatory bowel disease. Appropriate use of diet and nutritional therapy is integral to the overall management strategy of Crohn's disease. The aim was to develop evidence-based guidelines on the dietary management of Crohn's disease in adults. METHODS Questions relating to the dietary management of Crohn's disease were developed. These included the roles of enteral nutrition to induce remission, food re-introduction diets to structure food re-introduction and maintain remission, and dietary management of stricturing disease, as well as whether probiotics or prebiotics induce or maintain remission. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus and Web of Science. Evidence statements, recommendations, practical considerations and research recommendations were developed. RESULTS Fifteen research papers were critically appraised and the evidence formed the basis of these guidelines. Although corticosteroids appear to be more effective, enteral nutrition (elemental or non-elemental) can be offered as an alternative option to induce disease remission. After a course of enteral nutrition, food re-introduction diets may be useful to structure food re-introduction and help maintain disease remission. Dietary fibre is contraindicated in the presence of strictures as a result of the risk of mechanical obstruction. The use of probiotics and prebiotics is not currently supported. CONCLUSIONS As an alternative to corticosteroids, evidence supports enteral nutrition to induce disease remission. Food re-introduction diets provide structure to food re-introduction and help maintain disease remission. These guidelines aim to reduce variation in clinical practice.
Collapse
Affiliation(s)
- J Lee
- Department of Nutrition and Dietetics, Addenbrookes, Cambridge, UK
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
102
|
Pagnini C, Fave GD, Bamias G. Probiotics in inflammatory bowel disease: Pathophysiological background and clinical applications. World J Immunol 2013; 3:31-43. [DOI: 10.5411/wji.v3.i3.31] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 08/06/2013] [Accepted: 08/13/2013] [Indexed: 02/05/2023] Open
Abstract
Ulcerative colitis and Crohn’s disease, collectively termed the inflammatory bowel diseases (IBD), are chronic inflammatory disorders of the gastrointestinal tract. A “dysbiotic” relationship between the commensal gut flora and the intestinal mucosa-associated immune system has been at the core of the pathogenesis of these conditions. Probiotics are “good bacteria” with the ability to benefit the health of the host and their therapeutic application has been studied in IBD. The theoretical basis for such utilization relies upon the ability of probiotic microorganisms to interfere with the dysregulated homeostasis that takes place in IBD and restore the immune-bacterial interaction at the intestinal mucosa. Proposed mechanisms of action include the reconstitution of altered flora composition, enhancement of the integrity of the epithelial barrier, promotion of tolerogenic action by dendritic cells, strengthening of the defensive mechanisms of the innate immunity, and the suppression of pro-inflammatory adaptive immune responses. Despite this abundance of supporting experimental evidence, clinical application of probiotics in IBD has been disappointing. Possible explanations for such discrepancy include the great diversity of microorganisms that fall under the definition of probiotics, the lack of standardization of dosages and administration schemes, the heterogeneity between clinical trials, and the inclusion in the treatment arms of patients with a large variety of clinical phenotypes. Addressing these important issues will be critical for the optimal usage of probiotic-based therapies for patients with IBD.
Collapse
|
103
|
Renna S, Orlando A, Cottone M. Comparing medical treatments for Crohn's disease. J Comp Eff Res 2013; 2:135-49. [PMID: 24236556 DOI: 10.2217/cer.13.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The drugs available for inflammatory bowel disease are aminosalicylates, antibiotics, steroids, immunosuppressors and biologics. The effectiveness of these drugs has been evaluated in many randomized clinical trials, mainly versus placebo. Few studies have been conducted comparing the different drugs among themselves, owing to the methodological problems raised by comparative trials, such as sample size and blindness. This review focuses mainly on the randomized clinical trials that have compared different treatments. Of course comparisons are mainly between drugs used in a particular setting (mild, moderate and severe disease). However, on many occasions there is no homogeneity in these clinical settings, and therefore the results are difficult to interpret.
Collapse
Affiliation(s)
- Sara Renna
- DI.BI.MIS., Division of Internal Medicine "Villa Sofia-V. Cervello" Hospital, University of Palermo, Palermo, Italy
| | | | | |
Collapse
|
104
|
Abstract
Ample research has described multiple biological activities of probiotics in animals and in humans. Probiotics interfere with local and systemic immune reactions and thus exert an influence on the barrier function of the intestinal mucosa. Therefore, attempting inflammatory bowel disease treatment with probiotics seems reasonable. In fact, a growing number of trials have studied the therapeutic effects in ulcerative colitis and Crohn's disease. Promising results have been found and in some, indications such as maintenance of remission of ulcerative colitis and pouchitis guidelines recommend therapy with probiotics already today. However, many open questions still remain and the urgent need for high-quality trials requires much more research in the future.
Collapse
Affiliation(s)
- Wolfgang Kruis
- Evangelisches Krankenhaus Kalk, University of Cologne, Cologne, Germany
| |
Collapse
|
105
|
Bertazzoni E, Donelli G, Midtvedt T, Nicoli J, Sanz Y. Probiotics and clinical effects: is the number what counts? J Chemother 2013; 25:193-212. [DOI: 10.1179/1973947813y.0000000078] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
106
|
Özdemir Ö. Any role for probiotics in the therapy or prevention of autoimmune diseases? Up-to-date review. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2013; 10:/j/jcim.2013.10.issue-1/jcim-2012-0054/jcim-2012-0054.xml. [PMID: 23921494 DOI: 10.1515/jcim-2012-0054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 07/02/2013] [Indexed: 01/01/2023]
Abstract
Probiotic use as capable preventive and therapeutic strategy in different diseases varying from allergic to autoimmune disease (AD) has been recently reported. Three interacting factors including an aberrant intestinal microbiota, a "leaky" intestinal mucosal barrier, and altered intestinal immune responsiveness have been suggested to be able to create a "perfect environment" for AD development. Regulation of intestinal microflora composition by probiotics offers the possibility to influence the development of mucosal/systemic immunity besides ADs. Moreover, with various strains of probiotics, development and/or stimulation of T helper type 2 (Th2)-mediated immune responses causing exacerbation of atopic disease have been described. Similarly, certain probiotics are known to stimulate Th1 immunity, which has been suggested as one of the mechanisms by which they can suppress Th2-mediated allergic diseases. Consequently, this presumed that excessive immunostimulation might aggravate or induce Th1-mediated immune responses and diseases such as type 1 diabetes, multiple sclerosis, and it might cause an additional safety issue. Although there is a large amount of conflicting data on the preventive/therapeutic effects of probiotics in ADs, there is fairly promising evidence to recommend as well. Thus, probiotic use cannot be generally recommended for primary prevention and therapy of ADs for now.
Collapse
Affiliation(s)
- Öner Özdemir
- Pediatric Allergy-Immunology, Sakarya University Faculty of Medicine, Research/Training Hospital, Adapazarı, Sakarya, Turkey.
| |
Collapse
|
107
|
Sorrentino D. State-of-the-art medical prevention of postoperative recurrence of Crohn's disease. Nat Rev Gastroenterol Hepatol 2013; 10:413-22. [PMID: 23648935 DOI: 10.1038/nrgastro.2013.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Postoperative recurrence of Crohn's disease is a frequent and often severe sequela of the disease. Until a few years ago it was deemed inescapable, as all the conventional medications used to treat the disease have been proven of little benefit in preventing recurrence after surgical treatment. In the past few years, anti-TNF agents given immediately after surgery have shown a remarkable efficacy in the prevention of disease recurrence. Large, randomized, controlled trials are currently underway to confirm these findings. Anti-TNF treatment of endoscopic lesions that occur after surgery seems to be less effective than using TNF antagonists to prevent recurrence. However, although the data are limited, this treatment strategy seems to be still superior to all the other prevention strategies that are not based on anti-TNF agents. Limited data are available on long-term outcomes of patients treated with anti-TNF agents after surgery. They suggest that these medications are safe and effective after many years of treatment. In addition, these agents might prevent recurrence even at doses lower than those used in patients with Crohn's disease who have not had surgery.
Collapse
Affiliation(s)
- Dario Sorrentino
- Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA 24016, USA.
| |
Collapse
|
108
|
Andrews JM, Tan M. Probiotics in luminal gastroenterology: the current state of play. Intern Med J 2013; 42:1287-91. [PMID: 23252997 DOI: 10.1111/imj.12015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 08/16/2012] [Indexed: 12/11/2022]
Abstract
In recent years, there has been a growing interest in the use of probiotics in various areas of gastrointestinal (GI) health. Probiotics are defined as live microorganisms that provide beneficial health effects on the host when administered in adequate amounts. Various probiotics have been shown to suppress bacterial growth, modulate the immune system and improve intestinal barrier function. However, despite several studies with promising results, most trials are small and many have substantial methodological limitations. However, with better targeting and appropriate randomised controlled trials, this area may soon yield important therapeutic strategies to optimise GI health. Here, we review the current knowledge of probiotics of relevance to luminal GI health.
Collapse
Affiliation(s)
- J M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | | |
Collapse
|
109
|
Caselli M, Cassol F, Calò G, Holton J, Zuliani G, Gasbarrini A. Actual concept of "probiotics": Is it more functional to science or business? World J Gastroenterol 2013; 19:1527-1540. [PMID: 23539674 PMCID: PMC3602470 DOI: 10.3748/wjg.v19.i10.1527] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Revised: 12/18/2012] [Accepted: 01/13/2013] [Indexed: 02/06/2023] Open
Abstract
It is our contention that the concept of a probiotic as a living bacterium providing unspecified health benefits is inhibiting the development and establishment of an evidence base for the growing field of pharmacobiotics. We believe this is due in part to the current regulatory framework, lack of a clear definition of a probiotic, the ease with which currently defined probiotics can be positioned in the market place, and the enormous profits earned for minimum investment in research. To avoid this, we believe the following two actions are mandatory: international guidelines by a forum of stakeholders made available to scientists and clinicians, patient organizations, and governments; public research funds made available to the scientific community for performing independent rigorous studies both at the preclinical and clinical levels.
Collapse
|
110
|
Might patients with immune-related diseases benefit from probiotics? Nutrition 2013; 29:583-6. [DOI: 10.1016/j.nut.2012.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 10/11/2012] [Accepted: 10/11/2012] [Indexed: 12/25/2022]
|
111
|
Veerappan GR, Betteridge J, Young PE. Probiotics for the treatment of inflammatory bowel disease. Curr Gastroenterol Rep 2012; 14:324-33. [PMID: 22581276 DOI: 10.1007/s11894-012-0265-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Probiotics are organisms which provide a desired and beneficial effect on human health. With recent evidence implicating a disruption in the balance of the gastrointestinal microbiome and intestinal immunity as a potential trigger for inflammatory bowel disease (IBD), there has been growing interest in using probiotics as an adjunct to standard anti-inflammatory and immune suppressing therapy. Animal models describe potential and plausible mechanisms of action for probiotics to counter inflammation of colonic mucosa. Although there are insufficient data to recommend probiotics in ulcerative colitis or Crohn's disease, good evidence supports the use of specific probiotics for maintenance of remission in pouchitis. Although there are limited regulatory standards for the agents, probiotics are relatively safe with minimal reported side effects or contraindications. More rigorous studies need to be published supporting efficacy and safety of these agents before they become a mainstay of IBD medical treatment.
Collapse
Affiliation(s)
- Ganesh R Veerappan
- Gastroenterology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889-0001, USA.
| | | | | |
Collapse
|
112
|
Hashash JG, Regueiro MD. The evolving management of postoperative Crohn's disease. Expert Rev Gastroenterol Hepatol 2012; 6:637-48. [PMID: 23061713 DOI: 10.1586/egh.12.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.
Collapse
Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street-PUH, M2, C-Wing, Pittsburgh, PA 15213, USA.
| | | |
Collapse
|
113
|
Scaldaferri F, Pizzoferrato M, Pecere S, Forte F, Gasbarrini A. Bacterial flora as a cause or treatment of chronic diarrhea. Gastroenterol Clin North Am 2012; 41:581-602. [PMID: 22917165 DOI: 10.1016/j.gtc.2012.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intestinal microflora can be considered an organ of the body. It has several functions in the human gut, mostly metabolic and immunologic, and constantly interacts with the intestinal mucosa in a delicate equilibrium. Chronic diarrhea is associated with an alteration of gut microbiota when a pathogen invades the gut and also in several conditions associated with intestinal mucosal damage or bowel dysfunction, as in inflammatory bowel disease, irritable bowel syndrome, or small bowel bacterial overgrowth. This article discusses the basis of gut microbiota modulation. Evidence for the efficacy of gut microbiota modulation in chronic conditions is also discussed.
Collapse
Affiliation(s)
- Franco Scaldaferri
- Division of Internal Medicine and Gastroenterology, Policlinico A. Gemelli Hospital - Catholic University of Rome, Rome, Italy
| | | | | | | | | |
Collapse
|
114
|
Jonkers D, Penders J, Masclee A, Pierik M. Probiotics in the management of inflammatory bowel disease: a systematic review of intervention studies in adult patients. Drugs 2012; 72:803-23. [PMID: 22512365 DOI: 10.2165/11632710-000000000-00000] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Mounting evidence suggests an important role for the intestinal microbiota in the chronic mucosal inflammation that occurs in inflammatory bowel disease (IBD), and novel molecular approaches have further identified a dysbiosis in these patients. Several mechanisms of action of probiotic products that may interfere with possible aetiological factors in IBD have been postulated. OBJECTIVE Our objective was to discuss the rationale for probiotics in IBD and to systematically review clinical intervention studies with probiotics in the management of IBD in adults. METHODS A systematic search was performed in PubMed up to 1 October 2011, using defined keywords. Only full-text papers in the English language addressing clinical outcomes in adult patients were included. The 41 eligible studies were categorized on disease type (ulcerative colitis [UC] with/without an ileo-anal pouch and Crohn's disease [CD]) and disease activity. Pooled odds ratios were only calculated per probiotic for a specific patient group when more than one randomized controlled trial was available. RESULTS Well designed randomized controlled trials supporting the application of probiotics in the management of IBD are still limited. Meta-analyses could only be performed for a limited number of studies revealing overall risk ratios of 2.70 (95% CI 0.47, 15.33) for inducing remission in active UC with Bifido-fermented milk versus placebo or no additive treatment (n = 2); 1.88 (95% CI 0.96, 3.67) for inducing remission in active UC with VSL#3 versus placebo (n = 2); 1.08 (95% CI 0.86, 1.37) for preventing relapses in inactive UC with Escherichia coli Nissle 1917 versus standard treatment (n = 3); 0.17 (95% CI 0.09, 0.33) for preventing relapses in inactive UC/ileo-anal pouch anastomosis (IPAA) patients with VSL#3 versus placebo; 1.21 (95% CI 0.57, 2.57) for preventing endoscopic recurrences in inactive CD with Lactobacillus rhamnosus GG versus placebo (n = 2); and 0.93 (95% CI 0.63, 1.38) for preventing endoscopic recurrences in inactive CD with Lactobacillus johnsonii versus placebo (n = 2). CONCLUSION Further well designed studies based on intention-to-treat analyses by several independent research groups are still warranted to support the promising results for E. coli Nissle in inactive UC and the multispecies product VSL#3 in active UC and inactive pouch patients. So far, no evidence is available to support the use of probiotics in CD. Future studies should focus on specific disease subtypes and disease location. Further insight into the aetiology of IBD and the mechanisms of probiotic strains will aid in selecting probiotic strains for specific disease entities and disease locations.
Collapse
Affiliation(s)
- Daisy Jonkers
- Division of Gastroenterology-Hepatology, Research School Nutrim, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | | | | | | |
Collapse
|
115
|
Kinross JM, Markar S, Karthikesalingam A, Chow A, Penney N, Silk D, Darzi A. A Meta-Analysis of Probiotic and Synbiotic Use in Elective Surgery. JPEN J Parenter Enteral Nutr 2012; 37:243-53. [DOI: 10.1177/0148607112452306] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- James Macalister Kinross
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary’s Hospital, London, UK
| | - Sheraz Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | | | - Andre Chow
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary’s Hospital, London, UK
| | - Nicholas Penney
- Department of Plastic Surgery, Chelsea and Westminster Hospital, London, UK
| | - David Silk
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary’s Hospital, London, UK
| | - Ara Darzi
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary’s Hospital, London, UK
| |
Collapse
|
116
|
|
117
|
Prevention of postoperative recurrence of Crohn's disease. J Crohns Colitis 2012; 6:637-46. [PMID: 22398096 DOI: 10.1016/j.crohns.2011.12.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 12/04/2011] [Accepted: 12/05/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Up to 75% of patients with Crohn's disease (CD) will have intestinal resection during their life. Most patients will, however, develop postoperative recurrence (endoscopic, clinical or surgical). Several medical and surgical strategies have been attempted to prevent postoperative recurrence. This review evaluates the efficacy of different drug regimens and surgical techniques in the prevention of clinical, endoscopic and surgical postoperative recurrence of CD. METHODS A literature search for randomized controlled trials on medical or surgical interventions was performed. The endpoints for efficacy were clinical, endoscopic and surgical recurrence. Meta-analyses were performed in case two or more RCTs evaluated the same drug or surgical technique. RESULTS Mesalamine is more effective in preventing clinical recurrence than placebo (P=0,012), as well as nitroimidazolic antibiotics at one year follow-up (P<0.001) and thiopurines (P=0.018). Nitroimidazolic antibiotics are also more effective than placebo in preventing endoscopic recurrence (P=0.037), as well as thiopurines (P=0.015) and infliximab (P=0.006). Budenoside, probiotics, Interleukin-10 nor any of the different surgical procedures showed any significant difference compared to placebo in postoperative recurrence rates of CD. CONCLUSION Among the different drug regimens and surgical techniques, only thiopurines and nitroimidazolic antibiotics are able to reduce postoperative clinical as well as endoscopic recurrence of CD. Mesalamine and infliximab also seem to be superior to placebo in preventing clinical recurrence and endoscopic recurrence, respectively. There is a paucity of trials evaluating long-term follow-up and prevention of surgical recurrence of CD.
Collapse
|
118
|
Buisson A, Chevaux JB, Bommelaer G, Peyrin-Biroulet L. Diagnosis, prevention and treatment of postoperative Crohn's disease recurrence. Dig Liver Dis 2012; 44:453-60. [PMID: 22265329 DOI: 10.1016/j.dld.2011.12.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 12/17/2011] [Indexed: 12/11/2022]
Abstract
Ileocolonoscopy remains the gold standard in diagnosing postoperative recurrence. After excluding stricture, wireless capsule endoscopy seemed accurate in small series, but no validated score is available. Ultrasonography is a non-invasive diagnostic method reducing radiation exposure and emerging as an alternative tool for identifying post-operative recurrence. Computed tomography enteroclysis yields objective morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site, but ionising radiation exposure limits its use. Magnetic resonance imaging may be as powerful as ileocolonoscopy in diagnosing postoperative recurrence and in predicting the clinical outcome using specific MR-scores. Biomarkers such as faecal calprotectin and faecal lactoferrin showed promising results, but their specificity in the postoperative period will require further investigation. Numerous medications have been tested to prevent and/or to treat postoperative recurrence. Efficacy of mesalamine is very low and comparable to placebo in most series. Thiopurines have modest efficacy in the postoperative setting and are associated with a high rate of adverse events leading to drug withdrawal. Antibiotics such as metronidazole or ornidazole may be effective, but toxicity and drug resistance prevent their long-term use. Anti-Tumour Necrosis Factor therapy is the most potent drug class to prevent and to treat postoperative recurrence in Crohn's disease.
Collapse
Affiliation(s)
- Anthony Buisson
- Department of Hepato-Gastroenterology, University Hospital Estaing of Clermont-Ferrand, Auvergne University, Clermont-Ferrand, France
| | | | | | | |
Collapse
|
119
|
Zhou FX, Chen L, Liu XW, Ouyang CH, Wu XP, Wang XH, Wang CL, Lu FG. Lactobacillus crispatus M206119 exacerbates murine DSS-colitis by interfering with inflammatory responses. World J Gastroenterol 2012; 18:2344-56. [PMID: 22654425 PMCID: PMC3353368 DOI: 10.3748/wjg.v18.i19.2344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/01/2012] [Accepted: 02/16/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the role of Lactobacillus crispatus (L. crispatus) strain China Center for Type Culture Collection (CCTCC) M206119 in intestinal inflammation.
METHODS: Forty 8-wk-old Balb/c mice (20 ± 2 g) were divided into four groups of 10 mice each. Three groups that had received dextran sulfate sodium (DSS) were administered normal saline, sulfasalazine or CCTCC M206119 strain, and the fourth group received none of these. We assessed the severity of colitis using a disease activity index, measured the colon length and weight, collected stools and mesenteric lymph nodes for bacterial microflora analysis. One centimeter of the proximal colon, middle colon and distal colon were collected and fixed in 10% buffered formalin, dehydrated in ethanol, and embedded in paraffin. Interleukin (IL)-1β, IL-6 and tumor necrosis factor (TNF)-α expression was detected using reverse transcription polymerase chain reaction. Protective factors zonula occludens (ZO)-1 and β-defensin 2 were detected by immunoblotting. The features of CCTCC M206119 strain were identified based on morphology, biochemical profile, and 16S RNA sequencing.
RESULTS: DSS-colitis animals treated with CCTCC M206119 had markedly more severe disease, with greater weight loss, diarrhea, fecal bleeding, and shortened colon length. In addition, the CCTCC-M206119-treated group had comparatively higher histological scores and more neutrophil infiltration than the controls. Expression of protective factors ZO-1 and β-defensin 2 was downregulated due to destruction of the mucosal barrier after CCTCC M206119 strain treatment. An in vitro assay demonstrated that CCTCC M206119 strain increased the nuclear translocation of nuclear factor-κB in epithelial cells. Intestinal proinflammatory or anti-inflammatory cytokine responses were evaluated. Proinflammatory colonic cytokine (IL-1β, IL-6 and TNF-α) levels were clearly increased in CCTCC-M206119-treated animals, whereas anti-inflammatory colonic cytokine (IL-10) level was lowered compared with saline or 5-aminosalicylic-acid-treated DSS-colitis mice. Next, CCTCC M206119 strain was characterized as L. crispatus by microscopic morphology, biochemical tests and 16S rRNA gene level.
CONCLUSION: Not all lactobacilli are beneficial for intestinal inflammation, and L. crispatus CCTCC M206119 strain is involved in exacerbation of intestinal inflammation in DSS-colitis mice.
Collapse
|
120
|
De Cruz P, Kamm MA, Prideaux L, Allen PB, Desmond PV. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18:758-77. [PMID: 21830279 DOI: 10.1002/ibd.21825] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/15/2011] [Indexed: 12/20/2022]
Abstract
Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.
Collapse
Affiliation(s)
- Peter De Cruz
- Department of Gastroenterology and Medicine, St Vincent's Hospital, Melbourne, Australia
| | | | | | | | | |
Collapse
|
121
|
Malaguarnera G, Leggio F, Vacante M, Motta M, Giordano M, Bondi A, Basile F, Mastrojeni S, Mistretta A, Malaguarnera M, Toscano MA, Salmeri M. Probiotics in the gastrointestinal diseases of the elderly. J Nutr Health Aging 2012; 16:402-10. [PMID: 22499466 DOI: 10.1007/s12603-011-0357-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Changes of the gut microflora in elderly appear to involve a reduction in numbers of healthy bacteria (lactobacilli and bifidobacteria) and an increase in numbers of potentially pathogenic species. These changes are generally described as gastrointestinal disorders and infections. This review analyses benefits of probiotics in old people, with particular interesting for the latest researches relevant to elderly people, e.g. trials examining enteric infections, antibiotic-associated diarrhea and Clostridium difficile associated diarrhea, functional bowel problems (constipation and irritable bowel syndrome), inflammatory bowel diseases, stimulation of the immune system and prevention of cancer. A growing number of researches indicates that some probiotic strains may help to maintain the health in old people, suggesting both health and cost-saving benefits in offering fermented dairy products. These benefits include: establishment of balanced intestinal microflora; improving colonization resistance and or prevention of diarrhea; reduction of fecal enzymes; reduction of serum cholesterol; reduction of potential mutagenes; reduction of lactose intolerance; synthesis of vitamins; predigestion of proteins.
Collapse
Affiliation(s)
- G Malaguarnera
- Department of Microbiology, University of Catania, Catania, Italy
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
122
|
Ringel-Kulka T. Targeting the intestinal microbiota in the pediatric population: a clinical perspective. Nutr Clin Pract 2012; 27:226-34. [PMID: 22402406 DOI: 10.1177/0884533612439895] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The intestinal microbiota is a functional organ with a variety of important metabolic, trophic, immunologic, and digestive activities. Current data suggest that alterations in the intestinal microbiota may be related to disease conditions. Manipulation of the intestinal microbiota such as with probiotics, prebiotics, and synbiotics may be beneficial in preventing and treating certain disease conditions. This article provides an overview of the evidence gathered through randomized clinical trials, reviews, and meta-analyses on probiotics and prebiotics in commonly studied conditions in the pediatric population. It concludes with current recommendations for their use, noting safety and gaps in clinical evidence.
Collapse
Affiliation(s)
- Tamar Ringel-Kulka
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7445, USA.
| |
Collapse
|
123
|
Buisson A, Chevaux JB, Allen PB, Bommelaer G, Peyrin-Biroulet L. Review article: the natural history of postoperative Crohn's disease recurrence. Aliment Pharmacol Ther 2012; 35:625-33. [PMID: 22313322 DOI: 10.1111/j.1365-2036.2012.05002.x] [Citation(s) in RCA: 245] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 10/16/2011] [Accepted: 01/08/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical resection of the diseased bowel in Crohn's disease is unfortunately not curative, and postoperative recurrence remains a problem in these patients. AIM To review the rates of and risk factors for clinical and endoscopic recurrence in population-based studies, referral centres and randomised controlled trials. METHODS We searched MEDLINE (source PUBMED, 1966 to September, 2011). RESULTS In randomised controlled trials, clinical recurrence in the first year after surgery occurred in 10-38% of patients, whereas endoscopic recurrence in the first year was reported in 35-85% of patients. In population-based studies, approximately half of patients experienced clinical recurrence at 10 years. In referral centres, 48-93% of the patients had endoscopic lesions (Rutgeerts' score ≥1) in the neoterminal ileum within 1 year after surgery, whereas 20-37% had symptoms suggestive of clinical recurrence. Three years after surgery, the endoscopic postoperative recurrence rate increased to 85-100%, and symptomatic recurrence occurred in 34-86% of patients. Smoking is the strongest risk factor for postoperative recurrence, increasing by twofold, the risk of clinical recurrence. Prior intestinal resection, penetrating behaviour, perianal disease and extensive bowel disease (>50 cm) are established risk factors for postoperative recurrence. Risk factors for postoperative recurrence remain poorly defined in population-based cohorts. CONCLUSION Endoscopic and clinical postoperative recurrence remains common in patients with Crohn's disease, and the identification of risk factors may allow targeted strategies to reduce this recurrence rate.
Collapse
Affiliation(s)
- A Buisson
- Department of Hepato-Gastroenterology, University Hospital Estaing of Clermont-Ferrand, Auvergne University, Clermont-Ferrand, France
| | | | | | | | | |
Collapse
|
124
|
Cottone M, Renna S, Orlando A, Mocciaro F. Medical management of Crohn's disease. Expert Opin Pharmacother 2012; 12:2505-25. [PMID: 21988215 DOI: 10.1517/14656566.2011.609556] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The medical approach to Crohn's disease has been modified in recent years thanks to the introduction of new therapies, like biologics. Also, well-designed studies and systematic reviews have allowed better evaluation of the role of old drugs like steroids and immunosuppressors. This review aims to evaluate the recent evidence on the medical approach to Crohn's disease in the different settings of the disease. AREAS COVERED Randomized controlled trials and meta-analyses were included in the review. The research on all the studies discussed was based on the Cochrane Library, Medline and Embase, using the following medical subject headings: Crohn's disease, clinical trial, therapy, 5-aminosalicylic acid, steroid, budesonide, immunosuppressant, anti-meta-analysis TNF and biologics. EXPERT OPINION In a mild active inflammatory ileocecal disease, budesonide is considered the best approach. The efficacy of aminosalicylates is limited, but a trial that has recently compared aminosalicylates and budesonide has shown that the two drugs are comparable. In a mild colonic disease, sulfasalazine, antibiotics and steroids are effective but the evidence for antibiotics is less clear. The maintenance of remission in this setting is debatable, but sulfasalazine seems the better choice. In a moderate severe ileal and colonic disease, steroids are the best therapy to induce remission. Once remission is reached, immunosuppressors remain today the better choice to maintain the remission. Anti-TNF therapy is indicated in patients intolerant or not responding to steroids and immunosuppressors and in fistulizing Crohn's disease. Early therapy with biologics may be considered in patients with severe disease.
Collapse
Affiliation(s)
- Mario Cottone
- University of Palermo, Villa Sofia-V. Cervello Hospital, Division of Internal Medicine, DI.BI.MIS, Via Trabucco 180, 90146, Palermo, Italy
| | | | | | | |
Collapse
|
125
|
The potential for probiotic manipulation of the gastrointestinal microbiome. Curr Opin Biotechnol 2011; 23:192-201. [PMID: 22137452 DOI: 10.1016/j.copbio.2011.11.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 11/07/2011] [Accepted: 11/07/2011] [Indexed: 12/26/2022]
Abstract
Multiple internal and external sites of the healthy human body are colonized by a diversity of symbiotic microbes. The microbial assemblages found in the intestine represent some of the most dense and diverse of these human-associated ecosystems. Unsurprisingly, the enteric microbiome, that is the totality of microbes, their combined genomes, and their interactions with the human body, has a profound impact on physiological aspects of mammalian function, not least, host immune response. Lack of early-life exposure to certain microbes, or shifts in the composition of the gastrointestinal microbiome have been linked to the development and progression of several intestinal and extra-intestinal diseases, including childhood asthma development and inflammatory bowel disease. Modulating microbial exposure through probiotic supplementation represents a long-held strategy towards ameliorating disease via intestinal microbial community restructuring. This field has experienced somewhat of a resurgence over the past few years, primarily due to the exponential increase in human microbiome studies and a growing appreciation of our dependence on resident microbiota to modulate human health. This review aims to review recent regulatory aspects related to probiotics in food. It also summarizes what is known to date with respect to human gastrointestinal microbiota - the niche which has been most extensively studied in the human system - and the evidence for probiotic supplementation as a viable therapeutic strategy for modulating this consortium.
Collapse
|
126
|
Abstract
Crohn's disease, ulcerative colitis, and pouchitis after ileal pouch anal anastomosis in ulcerative colitis patients are often refractory to standard therapy. Over the last decade, the rational to use probiotics and its beneficial efficacy in the treatment of chronic inflammatory bowel disease (IBD) is increasingly under scrutiny. Although it has become clear that intestinal epithelial-mucosal immune interactions and enteric bacteria play a critical role in the development of IBD, the substantial clinical efficacy of probiotics in these disorders is less evident. This review outlines the clinical studies regarding probiotics before October 2007. These studies formed the foundation of probiotic clinical trials in IBD, but they also indicated the need of larger and better-controlled studies than the past experimental approaches. Furthermore, this review also examines in-depth the probiotic clinical trials published between 2007 and December 2010, providing new insights into the role of probiotics for inducing and maintaining remission of IBD, and highlighting some of the breakthroughs, especially regarding induction of remission for ulcerative colitis.
Collapse
|
127
|
Consensus guidelines for the management of inflammatory bowel disease. ARQUIVOS DE GASTROENTEROLOGIA 2011; 47:313-25. [PMID: 21140096 DOI: 10.1590/s0004-28032010000300019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 07/20/2010] [Indexed: 12/16/2022]
Abstract
This is the first Brazilian Consensus on inflammatory bowel disease, carried out by the Brazilian Study Group of Inflammatory Bowel Disease, and discusses the treatment of Crohn's disease and ulcerative colitis in acute and remission phases. The first part of the text, brings out a review on the main drugs used in the treatment of inflammatory bowel disease, as well as their mechanisms of action and cautions during their use. In the second part, the committee's opinions about the most recommended medical and surgical approaches for both diseases are presented on the basis of disease activity, location and behaviour status. The recommendations here presented were widely discussed in several scientific meetings with active participation of all members of the group and were highly based on scientific evidence covered by the literature.
Collapse
|
128
|
Spinelli A, Sacchi M, Fiorino G, Danese S, Montorsi M. Risk of postoperative recurrence and postoperative management of Crohn’s disease. World J Gastroenterol 2011; 17:3213-9. [PMID: 21912470 PMCID: PMC3158397 DOI: 10.3748/wjg.v17.i27.3213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 11/12/2010] [Accepted: 11/19/2010] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory disease of the digestive tract with systemic manifestations. Etiology is unknown, even if immunological, genetic and environmental factors are involved. The majority of CD patients require surgery during their lifetime due to progressive bowel damage, but, even when all macroscopic lesions have been removed by surgery, the disease recurs in most cases. Postoperative management represents therefore a crucial mean for preventing recurrence. Several drugs and approaches have been proposed to achieve this aim. Endoscopic inspection of the ileocolic anastomosis within 1 year from surgery is widely encouraged, given that endoscopic recurrence is one of the greatest predictors for clinical recurrence. A strategy should be planned only after stratifying patients according to their individual risk of recurrence, avoiding unnecessary therapies when possible benefits are reduced, and selecting high-risk patients for more aggressive intervention.
Collapse
|
129
|
Efficacy of Lactobacillus casei treatment on small bowel injury in chronic low-dose aspirin users: a pilot randomized controlled study. J Gastroenterol 2011; 46:894-905. [PMID: 21556830 DOI: 10.1007/s00535-011-0410-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 03/09/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few studies have investigated measures to prevent small bowel injuries induced by aspirin. Our aim was to evaluate the effect of probiotic treatment on the small bowel injuries induced by chronic low-dose aspirin use. METHODS Thirty-five patients who took low-dose enteric-coated aspirin 100 mg daily (for more than 3 months) plus omeprazole 20 mg daily and were diagnosed as having unexplained iron deficiency anemia participated in this prospective randomized controlled trial. We assigned the patients to receive probiotic treatment with Lactobacillus casei for 3 months (L. casei group) or not receive the probiotic (control group). Patients underwent capsule endoscopy (CE) before and after treatment. RESULTS Twenty-five patients, including 13 in the L. casei group and 12 in the control group, underwent the full analysis. Significant decreases in the number of mucosal breaks and the CE score were observed at the 3-month evaluation in the L. casei group as compared with the results in the control group (P = 0.039). The change from the baseline in the median number of mucosal breaks in the L. casei group was -2, as compared with 0.5 in the control group. The change from the baseline in the median CE score in the L. casei group was -228 compared with -4 in the control group (P = 0.026). CONCLUSIONS Co-administration of L. casei is effective for the treatment of aspirin-associated small bowel injury.
Collapse
|
130
|
Abstract
Systemic and local inflammation in relation to the resident microbiota of the human gastro-intestinal (GI) tract and administration of probiotics are the main themes of the present review. The dominating taxa of the human GI tract and their potential for aggravating or suppressing inflammation are described. The review focuses on human trials with probiotics and does not include in vitro studies and animal experimental models. The applications of probiotics considered are systemic immune-modulation, the metabolic syndrome, liver injury, inflammatory bowel disease, colorectal cancer and radiation-induced enteritis. When the major genomic differences between different types of probiotics are taken into account, it is to be expected that the human body can respond differently to the different species and strains of probiotics. This fact is often neglected in discussions of the outcome of clinical trials with probiotics.
Collapse
|
131
|
Predicting, treating and preventing postoperative recurrence of Crohn's disease: the state of the field. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:140-6. [PMID: 21499578 DOI: 10.1155/2011/591347] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of patients diagnosed with Crohn's disease eventually require surgical intervention. Unfortunately, postsurgical remission tends to be short lived; a significant number of patients experience clinical relapse and many require additional operations. The pathogenesis of this postoperative recurrence is poorly understood and, currently, there are no reliable tools to predict when and in whom the disease will recur. Furthermore, the postoperative prophylaxis profiles of available Crohn's disease therapeutic agents such as 5-aminosalicylates, immunomodulators, steroids and probiotics have been disappointing. Recently, the combination of antibiotics and azathioprine in selected high-risk patients has demonstrated some potential for benefit. The goal of the present article is to provide a coherent summary of previous and new research to guide clinicians in managing the challenging and complex problem of postoperative Crohn's disease recurrence.
Collapse
|
132
|
Foley S, Garsed K, Singh G, Duroudier NP, Swan C, Hall IP, Zaitoun A, Bennett A, Marsden C, Holmes G, Walls A, Spiller RC. Impaired uptake of serotonin by platelets from patients with irritable bowel syndrome correlates with duodenal immune activation. Gastroenterology 2011; 140:1434-43.e1. [PMID: 21315720 DOI: 10.1053/j.gastro.2011.01.052] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 01/13/2011] [Accepted: 01/24/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Patients with irritable bowel syndrome with diarrhea (IBS-D) have increased mucosal serotonin (5-hydroxytryptamine [5-HT]) availability, possibly because immune activation reduces activity of the 5-HT transporter (SERT). We investigated the relationship between mucosal and platelet SERT and immune activation of the duodenal mucosa in patients with IBS-D. METHODS We quantified mucosal intraepithelial lymphocytes (IELs), mast cells, and enterochromaffin cells in blood samples, measured levels of SERT messenger RNA (mRNA) in mucosal samples, and assessed platelet uptake of 5-HT and platelet membrane binding of (3)H-paroxetine in samples from 29 healthy volunteers (HVs), 20 patients with IBS-D, and 20 untreated patients with celiac disease. RESULTS Patients with IBS-D or celiac disease had increased numbers of IELs and mast cells compared with HVs (both P < .001). Levels of SERT mRNA were reduced in the mucosa of patients with IBS-D or celiac disease and were inversely correlated with numbers of IELs (r = -0.72, P < .0001). Uptake of 5-HT by platelets from patients with IBS-D or celiac disease was reduced (mean, 17.1 ± 3.5 and 28.3 ± 4.1 nmol·min(-1)·mg(-1), respectively) compared with HVs (50.8 ± 8.0 nmol·min(-1)·mg(-1), P < .01 and P = .05, respectively). Binding of paroxetine to membranes of platelets from patients with IBS-D (median [interquartile range], 226 [92-405] fmol/mg protein) was significantly greater than that from HVs (109 [69-175] fmol/mg protein) and correlated inversely with platelet uptake of 5-HT (r = -0.62, P = .03). Tryptase release from incubated biopsy samples was significantly increased in patients with IBS-D (2.2 [0.42-3.5] vs 0.50 [0.25-0.86] ng·mL(-1)·mg(-1) for HVs; P = .03). CONCLUSIONS Platelet SERT is reduced in IBS-D and associated with reduced levels of SERT mRNA and duodenal immune activation.
Collapse
Affiliation(s)
- Stephen Foley
- National Institute for Health Research Biomedical Research Unit, Nottingham Digestive Diseases Centre, School of Clinical Sciences, Nottingham, England
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
133
|
Schwartz M, Regueiro M. Prevention and treatment of postoperative Crohn's disease recurrence: an update for a new decade. Curr Gastroenterol Rep 2011; 13:95-100. [PMID: 21042888 DOI: 10.1007/s11894-010-0152-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Poorly controlled Crohn's disease (CD) often requires surgery for such complications as strictures, fistulas, and abscesses. The goal of postoperative treatment is to suppress or prevent inflammation and maintain mucosal healing. Probiotics, antibiotics, 5-aminosalicylates, immunomodulators, and antibodies to tumor necrosis factor are all used to prevent postoperative recurrence. In this article, recent studies are reviewed. Azathioprine/6-mercaptopurine are moderately effective at preventing and treating postoperative CD, whereas infliximab/adalimumab are highly effective and probiotics and 5-aminosalicylates minimally effective. We base the choice of postoperative medical therapy on the patient's risk profile for postoperative recurrence. Whatever postoperative therapy is used, the mucosa should be assessed within 12 months to determine if the approach is effective. If active inflammation is found, then treatment should be intensified. By treating CD aggressively after a first surgery, future surgeries can be delayed or averted.
Collapse
Affiliation(s)
- Marc Schwartz
- University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | |
Collapse
|
134
|
Cunningham MF, Docherty NG, Coffey JC, Burke JP, O'Connell PR. Postsurgical recurrence of ileal Crohn's disease: an update on risk factors and intervention points to a central role for impaired host-microflora homeostasis. World J Surg 2011; 34:1615-26. [PMID: 20195604 DOI: 10.1007/s00268-010-0504-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence. METHODS The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed. RESULTS Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome. CONCLUSIONS Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).
Collapse
Affiliation(s)
- Michael F Cunningham
- Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | | | | | | | | |
Collapse
|
135
|
Gut microbiota, probiotics and inflammatory bowel disease. Arch Immunol Ther Exp (Warsz) 2011; 59:161-77. [PMID: 21445715 DOI: 10.1007/s00005-011-0122-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 12/13/2010] [Indexed: 02/07/2023]
Abstract
The colonization of humans with commensals is critical for our well-being. This tightly regulated symbiotic relationship depends on the flora and an intact mucosal immune system. A disturbance of either compound can cause intestinal inflammation. This review summarizes extrinsic and intrinsic factors contributing to intestinal dysbiosis and inflammatory bowel disease.
Collapse
|
136
|
Probiotics in inflammatory bowel diseases and associated conditions. Nutrients 2011; 3:245-64. [PMID: 22254095 PMCID: PMC3257670 DOI: 10.3390/nu3020245] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Revised: 01/17/2011] [Accepted: 02/15/2011] [Indexed: 02/07/2023] Open
Abstract
A complex set of interactions between the human genes encoding innate protective functions and immune defenses and the environment of the intestinal mucosa with its microbiota is currently considered key to the pathogenesis of the chronic inflammatory bowel diseases (IBD). Probiotics offer a method to potentially alter the intestinal microbiome exogenously or may provide an option to deliver microbial metabolic products to alter the chronicity of intestinal mucosal inflammation characterizing IBD. At present, there is little evidence for the benefit of currently used probiotic microbes in Crohn's disease or associated conditions affecting extra-intestinal organs. However, clinical practice guidelines are now including a probiotic as an option for recurrent and relapsing antibiotic sensitive pouchitis and the use of probiotics in mild ulcerative colitis is provocative and suggests potential for benefit in select patients but concerns remain about proof from trials.
Collapse
|
137
|
Iannitti T, Palmieri B. Therapeutical use of probiotic formulations in clinical practice. Clin Nutr 2010; 29:701-25. [PMID: 20576332 PMCID: PMC7172412 DOI: 10.1016/j.clnu.2010.05.004] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 05/05/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS The spreading of gastrointestinal diseases is growing all over the world. Although for some of them an effective therapeutic approach has been found, palliation rather than cure is very frequent due to a partial knowledge of their aetiology and pathogenesis. This review, analyzing the main clinical studies, aims at being a state of the art update of the use of probiotic formulations in daily practice. METHODS In this review we include all the most significant clinical trials involving the use of probiotic formulations for the treatment of several pathologies. RESULTS Dysbiosis has been observed in irritable bowel syndrome patients. Probiotics may exert a beneficial effect on Crohn's disease affected patients who have shown gut microbiota antigens and altered wall permeability. Moreover some probiotic formulations seem to enhance the therapy for Helicobacter Pylori reducing its pathogenic potential. Intestinal ecology imbalance has been also linked to cancer induction, allergy, skin and urogenital diseases. In addition probiotics administration seems to be particularly useful to ease post-operative complications. CONCLUSION Further future clinical trials, involving large numbers of patients, will be mandatory to achieve definite evidence of the preventive and curative role of probiotics in medical practice.
Collapse
Affiliation(s)
- T Iannitti
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK.
| | | |
Collapse
|
138
|
Nikfar S, Darvish-Da M, Abdollahi M. A Review and Meta-analysis of the Efficacy of Antibiotics and Probiotics in Management of Pouchitis. INT J PHARMACOL 2010. [DOI: 10.3923/ijp.2010.826.835] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
139
|
Abstract
Perturbation of bacterial microflora of the gastrointestinal (GI) tract may play an important role in the pathophysiology of some GI disorders. Probiotics have been used as a treatment modality for over a century. They may restore normal bacterial microflora and effect the functioning of the GI tract by a variety of mechanisms. Probiotics are not currently regulated and only few randomized controlled trials exist investigating their efficacy in different GI disorders. They are available in a variety of formulations and delivery systems making interpretation and comparison of studies even more difficult. The efficacy of probiotics, either as a single strain or a combination of probiotics, has been tested in antibiotic-associated diarrhea, Clostridium difficile colitis, infectious diarrhea, ulcerative colitis, Crohn's disease, pouchitis, and irritable bowel syndrome, among other disorders. Results of the studies are reviewed in this article and recommendations for probiotic use in these disorders are made. Although probiotics appear to be generally safe in an outpatient setting, the situation may be different in immunocompromised, hospitalized patients who may be at a greater risk of developing probiotic sepsis. No studies exist addressing the issue of safety specifically. Many questions regarding use of probiotics in GI disorders remain to be answered in future studies, such as most optimal doses, duration of treatment, physiological and immunological effects, efficacy of specific probiotics in specific disease states, and safety in debilitated patients.
Collapse
Affiliation(s)
- Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Susan Lucak
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 20, New York, NY 10032, USA
| |
Collapse
|
140
|
Shanahan F, Collins SM. Pharmabiotic manipulation of the microbiota in gastrointestinal disorders, from rationale to reality. Gastroenterol Clin North Am 2010; 39:721-6. [PMID: 20951927 DOI: 10.1016/j.gtc.2010.08.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The viewpoints of enthusiasts and skeptics in relation to the role of probiotics should not be allowed to distract clinicians from the bigger issue, which is the pivotal role of the microbiota in the protection against many disorders and in the pathogenesis of others. However, all probiotics, like all bacteria, are not created equal, and therapeutic deployment in a generic sense is as absurd as the administration of pills or tablets without regard for the nature of the active ingredient and the intended effect. The rationale for therapeutic manipulation or supplementation of the microbiota is sound in conditions where the intestinal ecosystem is poorly developed, such as in low birth weight neonates, or where it is profoundly disturbed, such as after broad-spectrum antibiotics. In other conditions, such as irritable bowel disorder (IBD), the efficacy of some, but not all, probiotics has been a welcome surprise. However, the impact of probiotics is likely to be modest and is probably more complicated in IBD. In choosing a probiotic strategy, clinicians should adhere to the principles of evidence-based therapeutics. These include: selection from a reputable supplier, with appropriate documentation of contents and shelf life; anticipation of strain-specific effects; avoidance of cocktails without documentation of the activities of each ingredient with absence of interstrain antagonism; and published evidence of efficacy from clinical trials.
Collapse
Affiliation(s)
- Fergus Shanahan
- Department of Medicine, Alimentary Pharmabiotic Centre, University College Cork, National University of Ireland, Ireland.
| | | |
Collapse
|
141
|
Cary VA, Boullata J. What is the evidence for the use of probiotics in the treatment of inflammatory bowel disease? J Clin Nurs 2010; 19:904-16. [PMID: 20492035 DOI: 10.1111/j.1365-2702.2009.03123.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES The purpose of this article is to investigate the use of probiotics in the treatment of inflammatory bowel disease. BACKGROUND Probiotics have been successfully used to treat various acute illnesses such as Clostridium difficile infection, rotovirus diarrhoea and traveller's diarrhoea. Recently, some studies have reported success with probiotics in the treatment of chronic intestinal diseases such as inflammatory bowel disease. DESIGN Literature review. METHODS A literature search was performed to include studies on Bifidobacteria-fermented milk, Escherichia coli, Lactobacillus, Saccharomyces boulardii, VSL #3 and probiotic use. Results of the literature are analysed, and a discussion is made regarding evaluation of the literature and implications for care. RESULTS The majority of probiotics studied have proven to have beneficial effects in the treatment of inflammatory bowel disease, especially when taken as a dietary adjunctive to standard treatment. All probiotics studied, with the exception of Lactobacillus GG and LA1, demonstrated positive results. CONCLUSIONS The increasing use of probiotics combined with the insufficient knowledge regarding the use of probiotics in treating inflammatory bowel disease requires that future multilevel, multicentre large randomised control trials be conducted to understand better the specific measures and effectiveness of such treatment. RELEVANCE TO CLINICAL PRACTICE Given that few clinical trials exist to study the potential role of probiotics in the treatment of inflammatory bowel disease, it is imperative that healthcare providers become knowledgeable about the use of probiotics and their effects on inflammatory bowel disease.
Collapse
Affiliation(s)
- Virginia A Cary
- BA, BSN, MEd, Registered Nurse, University of Pennsylvania, School of Nursing, Philadelphia, PA 19104-6096, USA.
| | | |
Collapse
|
142
|
Coudeyras S, Forestier C. Microbiote et probiotiques : impact en santé humaine. Can J Microbiol 2010; 56:611-50. [DOI: 10.1139/w10-052] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
All accessible mucous membranes of the human body are colonized by an abundant and diversified microbial flora called microbiota. Recent studies have shown that these microorganisms, long regarded as purely commensal, have essential beneficial effects on human health. Thus, numerous human ailments are linked to dysbiosis; that is, imbalances in the microflora composition. The administration of probiotic microorganisms could, in some situations, provide substantial relief from such disorders. These live microorganisms, which, according to the definition, confer a health benefit to the host when administered in adequate amounts, are often derived from human flora and belong mostly to lactic acid bacteria, in particular to the genus Lactobacillus . The constant improvement of knowledge of the role of human microbiota and the growing popularity of probiotics are now opening the door to new prophylactic and therapeutic strategies in human health.
Collapse
Affiliation(s)
- Sophie Coudeyras
- Université Clermont 1, UFR Pharmacie, Laboratoire de Bactériologie, Clermont Ferrand, France
| | - Christiane Forestier
- Université Clermont 1, UFR Pharmacie, Laboratoire de Bactériologie, Clermont Ferrand, France
| |
Collapse
|
143
|
Bernstein CN. Anti-tumor necrosis factor therapy in Crohn's disease: more information and more questions about the long term. Clin Gastroenterol Hepatol 2010; 8:556-8. [PMID: 20417722 DOI: 10.1016/j.cgh.2010.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 04/15/2010] [Accepted: 04/16/2010] [Indexed: 02/07/2023]
|
144
|
Haller D, Antoine JM, Bengmark S, Enck P, Rijkers GT, Lenoir-Wijnkoop I. Guidance for substantiating the evidence for beneficial effects of probiotics: probiotics in chronic inflammatory bowel disease and the functional disorder irritable bowel syndrome. J Nutr 2010; 140:690S-7S. [PMID: 20107148 DOI: 10.3945/jn.109.113746] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Ulcerative colitis and Crohn's disease, the 2 distinct idiopathic pathologies of inflammatory bowel diseases, are spontaneously relapsing, immunologically mediated disorders of the gastrointestinal tract. Selected probiotics strains have been proven to be clinically effective in maintaining remission in patients with ulcerative colitis. None of the probiotics thus far tested has been shown to be effective in induction of remission or in maintenance of remission in patients with Crohn's disease. The multispecies probiotics mixture of 8 strains seems effective in the maintenance of remission in pouchitis. Irritable bowel syndrome is a functional bowel disorder manifested by chronic, recurring abdominal pain or discomfort associated with disturbed bowel habit in the absence of structural abnormalities likely to account for these symptoms. Recently conducted appropriately powered studies with different (combinations of) probiotics show positive results on reduction of symptoms, although a considerable placebo effect is also found. Mechanistic studies aimed at pathophysiological mechanisms of inflammatory bowel diseases can identify new targets for probiotic bacteria.
Collapse
Affiliation(s)
- Dirk Haller
- Chair for Biofunctionality, ZIEL-Research Center for Nutrition and Food Science, Technische Universität München, Freising-Weihenstephan, Germany
| | | | | | | | | | | |
Collapse
|
145
|
Shen J, Ran HZ, Yin MH, Zhou TX, Xiao DS. Meta-analysis: the effect and adverse events of Lactobacilli versus placebo in maintenance therapy for Crohn disease. Intern Med J 2010; 39:103-9. [PMID: 19220543 DOI: 10.1111/j.1445-5994.2008.01791.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lactobacilli are used in an attempt to maintain remission for Crohn disease. The aim of this study was to evaluate the efficacy and adverse events of Lactobacilli compared with placebo in maintenance therapy for Crohn disease. METHODS We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, OVID and BIOSIS. All randomized trials comparing Lactobacilli with placebo in maintenance therapy for Crohn disease were included. RESULTS Six randomized controlled trials with a total of 359 participants met the inclusion criteria. From the meta-analyses, the relative risk (RR) of clinical relapse rate was 1.15 (95% confidence interval (CI) 0.90-1.48) comparing Lactobacilli with placebo and RR of endoscopic relapse rate was 1.31 (95%CI 0.57-3.00). Subgroup analyses showed RR for clinical relapse rates of Lactobacilli versus placebo was 0.99 (95%CI 0.76-1.29) in adults, 1.85 (95%CI 1.00-3.41) in children, 1.68 (95%CI 1.07-2.64) in Lactobacillus rhamnosus strain GG and 0.91 (95%CI 0.68-1.23) in Lactobacillus johnsonii respectively. The pooled RR of adverse events was 0.83 (95%CI 0.61-1.12). CONCLUSION Our meta-analysis suggests that compared with placebo, administration of L. rhamnosus strain GG as maintenance therapy may increase the relapse rates of Crohn disease. L. johnsonii is inefficacious in reducing the incidence of relapse.
Collapse
Affiliation(s)
- J Shen
- Department of Gastroenterology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai Institute of Digestive Disease, Shanghai, China
| | | | | | | | | |
Collapse
|
146
|
Van Assche G, Dignass A, Reinisch W, van der Woude CJ, Sturm A, De Vos M, Guslandi M, Oldenburg B, Dotan I, Marteau P, Ardizzone A, Baumgart DC, D'Haens G, Gionchetti P, Portela F, Vucelic B, Söderholm J, Escher J, Koletzko S, Kolho KL, Lukas M, Mottet C, Tilg H, Vermeire S, Carbonnel F, Cole A, Novacek G, Reinshagen M, Tsianos E, Herrlinger K, Oldenburg B, Bouhnik Y, Kiesslich R, Stange E, Travis S, Lindsay J. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. J Crohns Colitis 2010; 4:63-101. [PMID: 21122490 DOI: 10.1016/j.crohns.2009.09.009] [Citation(s) in RCA: 526] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/28/2009] [Accepted: 09/28/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Gert Van Assche
- Division of Gastroenterology, Leuven University Hospitals, 49 Herestraat, BE 3000, Leuven, Belgium.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
147
|
Reid G, Gaudier E, Guarner F, Huffnagle GB, Macklaim JM, Munoz AM, Martini M, Ringel-Kulka T, Sartor BR, Unal RR, Verbeke K, Walter J. Responders and non-responders to probiotic interventions: how can we improve the odds? Gut Microbes 2010; 1:200-4. [PMID: 21637034 PMCID: PMC3023600 DOI: 10.4161/gmic.1.3.12013] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
As with many clinical studies, trials using probiotics have shown clearly that some patients benefit from the treatment while others do not. For example if treatment with probiotics leads to 36% cure rate of diarrhea, why did the other 64% not have the same result? The issue is important for human and indeed experimental animal studies for two main reasons: (i) Would changing the design of the study result in more subjects responding to treatment? (ii) If a subject does not respond what are the mechanistic reasons? In order to tackle the issue of responders and non-responders to therapy, a workshop was held by the International Scientific Association for Probiotics and Prebiotics (ISAPP). The outcome was four recommendations. 1. Clearly define the end goal: this could be supporting a health claim or having the highest clinical effect and impact. 2. Design the study to maximize the chance of a positive response by identifying precise parameters and defining the level of response that will be tested. 3. Base the selection of the intervention on scientific investigations: which strain(s) and/or product formulation should be used and why. 4. Carefully select the study cohort: use biological or genetic markers when available to stratify the patient population before enrollment and decide at what point intervention will provide the best outcome (for example, in acute phase of disease, or during remission, with or without use of pharmaceutical agents). By following these recommendations and selecting an appropriate primary outcome, it is hoped that clinical data will emerge in the future that expands our knowledge of which probiotics benefits which subjects and by what mechanism.
Collapse
Affiliation(s)
- Gregor Reid
- Canadian Research and Development Centre for Probiotics; Lawson Health Research Institute; London, Canada,Departments of Microbiology, Immunology and Surgery; The University of Western Ontario; London, Canada
| | - Estelle Gaudier
- Unilever Research & Development Vlaardingen; The Netherlands
| | - Francisco Guarner
- Digestive System Research Unit; Hospital Vall d'Hebron; CIBEREHD; Barcelona, Spain
| | - Gary B Huffnagle
- Division of Pulmonary & Critical Care Medicine; Department of Internal Medicine; University of Michigan; USA
| | - Jean M Macklaim
- Canadian Research and Development Centre for Probiotics; Lawson Health Research Institute; London, Canada
| | - Alicia Murcia Munoz
- Digestive System Research Unit; Hospital Vall d'Hebron; CIBEREHD; Barcelona, Spain
| | | | - Tamar Ringel-Kulka
- UNC Gillings School of Global Public Health; The University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Balfor R Sartor
- UNC Department of Medicine/Division of Gastroenterology and Hepatology; and Department of Microbiology and Immunology; Chapel Hill, NC USA
| | | | - Kristin Verbeke
- Department of Gastroenterology and Leuven Food Science and Nutrition Research Centre (LFoRCe); Katholieke Universiteit Leuven; Leuven, Belgium
| | - Jens Walter
- Department of Food Science and Technology; University of Nebraska; Lincoln, USA
| | | |
Collapse
|
148
|
|
149
|
Juillerat P, Vader JP, Felley C, Pittet V, Gonvers JJ, Mottet C, Bemelman WA, Lémann M, Oresland T, Michetti P, Froehlich F. Appropriate maintenance treatment for Crohn's disease: Results of a multidisciplinary international expert panel - EPACT II. J Crohns Colitis 2009; 3:241-9. [PMID: 21172282 DOI: 10.1016/j.crohns.2009.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 05/13/2009] [Accepted: 05/13/2009] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Biological therapy has dramatically changed management of Crohn's disease (CD). New data have confirmed the benefit and relative long-term safety of anti-TNFα inhibition as part of a regular scheduled administration programme. The EPACT appropriateness criteria for maintenance treatment after medically-induced remission (MIR) or surgically-induced remission (SIR) of CD thus required updating. METHODS A multidisciplinary international expert panel (EPACT II, Geneva, Switzerland) discussed and anonymously rated detailed, explicit clinical indications based on evidence in the literature and personal expertise. Median ratings (on a 9-point scale) were stratified into three assessment categories: appropriate (7-9), uncertain (4-6 and/or disagreement) and inappropriate (1-3). Experts ranked appropriate medication according to their own clinical practice, without any consideration of cost. RESULTS Three hundred and ninety-two specific indications for maintenance treatment of CD were rated (200 for MIR and 192 for SIR). Azathioprine, methotrexate and/or anti-TNFα antibodies were considered appropriate in 42 indications, corresponding to 68% of all appropriate interventions (97% of MIR and 39% of SIR). The remaining appropriate interventions consisted of mesalazine and a "wait-and-see" strategy. Factors that influenced the panel's voting were patient characteristics and outcome of previous treatment. Results favour use of anti-TNFα agents after failure of any immunosuppressive therapy, while earlier primary use remains controversial. CONCLUSION Detailed explicit appropriateness criteria (EPACT) have been updated for maintenance treatment of CD. New expert recommendations for use of the classic immunosuppressors as well as anti-TNFα agents are now freely available online (www.epact.ch). The validity of these criteria should now be tested by prospective evaluation.
Collapse
Affiliation(s)
- Pascal Juillerat
- Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland; Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
150
|
Doherty G, Bennett G, Patil S, Cheifetz A, Moss AC. Interventions for prevention of post-operative recurrence of Crohn's disease. Cochrane Database Syst Rev 2009:CD006873. [PMID: 19821389 DOI: 10.1002/14651858.cd006873.pub2] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recurrence of Crohn's disease is common after intestinal resection. A number of agents have been studied in controlled trials with the goal of reducing the risk of endoscopic or clinical recurrence of Crohn's disease following surgery. OBJECTIVES To undertake a systematic review of the use of medical therapies for the prevention of post-operative recurrence of Crohn's disease SEARCH STRATEGY MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify relevant studies. References from selected papers and abstracts from Digestive Disease Week were also searched. SELECTION CRITERIA Randomised controlled trials that compared medical therapy to placebo or other medical agents for the prevention of recurrence of intestinal Crohn's disease were selected for inclusion. DATA COLLECTION AND ANALYSIS Two authors reviewed all abstracts containing search terms, and those meeting inclusion criteria were selected for full data abstraction. Dichotomous data were summarised using relative risk and 95% confidence intervals. A fixed-effects model was used, and sensitivity analysis performed. MAIN RESULTS Twenty-three studies were identified for inclusion. Probiotics were not superior to placebo for any outcome measured. The use of nitroimidazole antibiotics appeared to reduce the risk of clinical (RR 0.23; 95%CI 0.09 to 0.57, NNT=4) and endoscopic (RR 0.44; 95%CI 0.26 to 0.74, NNT = 4) recurrence relative to placebo. However, these agents were associated with higher risk of serious adverse events (RR 2.39, 95% CI 1.5 to 3.7). Mesalamine therapy was associated with a significantly reduced risk of clinical recurrence (RR 0.76; 95% CI 0.62 to 0.94, NNT = 12), and severe endoscopic recurrence (RR 0.50; 95% CI 0.29 to 0.84, NNT = 8) when compared to placebo. Azathioprine/6MP was also associated with a significantly reduced risk of clinical recurrence (RR 0.59; 95% CI 0.38 to 0.92, NNT = 7), and severe endoscopic recurrence (RR 0.64; 95% CI 0.44 to 0.92, NNT = 4), when compared to placebo. Neither agent had a higher risk than placebo of serious adverse events. When compared to azathioprine/6MP, mesalamine was associated with a higher risk of any endoscopic recurrence (RR 1.45, 95% CI 1.03 to 2.06), but a lower risk of serious adverse events (RR 0.51; 95% CI 0.30 to 0.89). There was no significant difference between mesalamine and azathioprine/6MP for any other outcome. AUTHORS' CONCLUSIONS There are insufficient randomised controlled trials of infliximab, budesonide, tenovil and interleukin-10 to draw conclusions. Nitro-imidazole antibiotics, mesalamine and immunosuppressive therapy with azathioprine/6-MP or infliximab all appear to be superior to placebo for the prevention of post-operative recurrence of Crohn's disease. The cost, toxicity and tolerability of these approaches require careful consideration to determine the optimal approach for post-operative prophylaxis.
Collapse
Affiliation(s)
- Glen Doherty
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Rabb/Rose 1, East, Brookline Ave, Boston, MA, USA, 02215
| | | | | | | | | |
Collapse
|