Oral budesonide for active Crohn's disease. Canadian Inflammatory Bowel Disease Study Group

Medical therapy of inflammatory bowel disease

In the past years the advances in therapy of IBD have been characterized mainly by the more widespread use of immunosuppression. Especially azathioprine is currently used in Crohn's disease with methotrexate as the second-line immunosuppressive drug. Cyclosporin may become a drug of choice to treat severe ulcerative colitis but its effect in the long term is probably insufficient. Topically acting glucocorticosteroids have emerged as a valuable safer alternative to standard glucocorticosteroids (GCS) in right ileocolonic Crohn's disease but GCS have no role in maintenance therapy. The most significant development in recent years is the introduction of immunomodulatory treatments using cytokines and anticytokines. The first data show that anti-TNF monoclonal antibodies, especially cA2, not only may result in rapid control of active Crohn's disease but also achieve rapid tissue healing. Repeated administration of cA2 maintains remission. Immunomodulation therapy creates great expectations since early reset of the immunostat might be able to control inflammation in the long term. Safety will be a key issue.

Retrospective analysis of alternate-day prednisone maintenance therapy for Crohn's disease

We reviewed the medical records of 98 children with Crohn's disease followed at Children's Hospital of Pittsburgh from 1983 to 1993 to evaluate the merits of alternate-day prednisone (AD) maintenance therapy once initial remission was achieved. Of the 98 children, 35 had adequate data recorded for eligibility to the study. Of these, 11 were in the AD group and 24 were in a group whose maintenance regimen did not include prednisone (NO). The dependent variables were frequency of flares and linear growth over time. AD therapy reduced mean symptomatic flares (0.23 +/- 0.1 vs 0.69 +/- 0.14 flares/patient/year; p = 0.04) over a 2-year follow-up period but did not delay significantly the onset of a flare after remission was achieved (16.5 +/- 3.4, vs 13.4 +/- 1.8 months; p = 0.4). Site of disease involvement had no impact on frequency of flares. Fewer patients in the AD group experienced flares, but this finding did not achieve statistical significance (4/11, 36%, vs 17/24, 71%; p = 0.07). Linear growth, measured in height percentile and growth velocity (cm/year), was not significantly reduced by the second year of either therapy. This small retrospective study suggests that AD prednisone therapy may be effective in reducing symptomatic flares in Crohn's patients without a resultant inhibition of linear growth.

Bone turnover during short-term therapy with methylprednisolone or budesonide in Crohn's disease

BACKGROUND

Glucocorticosteroids are used frequently for the treatment of relapses of Crohn's disease.

AIM

To investigate the influence of the new topically active glucocorticosteroid budesonide in comparison with methylprednisolone on bone turnover in a randomized open trial.

METHODS

Twenty-nine patients received either budesonide (controlled ileal release formulation) 9 mg for 10 weeks, or methylprednisolone 32 mg (equivalent to 40 mg prednisone) orally for 3 weeks with subsequent tapering.

RESULTS

Patients who completed the trial with methylprednisolone (n = 8) had suppression of serum osteocalcin (30.2 +/- 2.6 to 20.4 +/- 2.0 ng/mL. P < 0.01), whereas no changes in this parameter of bone synthesis were observed during budesonide treatment (n = 11) (34.8 +/- 3.1 to 33.0 +/- 3.5 ng/mL). Urinary pyridinolines and deoxypyridinolines, highly sensitive markers of bone degradation, did not change in either group.

CONCLUSION

Short-term methylprednisolone therapy impairs osteoblast activity in patients with Crohn's disease whereas budesonide does not.

Medical therapy of active Crohn's disease

Active Crohn's disease constitutes a major problem in gastroenterology. Symptoms vary with site, extent and local complications of the disease as well as with the absence or presence of extraintestinal manifestations. Due to the troublesome consequences of the disease new treatments have continuously been tried. However, the results have varied and no definite breakthrough has occurred in the medical treatment of active Crohn's disease during the last years. The new salicylates have shown some effect using higher doses, but have not fulfilled the expectations once connected with their development. The new steroids have compared well to, but not exceeded, the older corticosteroid preparations in terms of therapeutic efficacy but they have a better side-effect profile. The role of the purine analogs azathioprine/6-mercaptopurine has been further evaluated. The onset of their effect is slow, an intravenous loading dose might shorten this time span, and they are steroid sparing. The controlled data on methotrexate are limited and the long-term effects not well studied and there is concern about toxicity. Even the use of cyclosporine in active Crohn's disease is controversial and connected with serious adverse events. Studies on the new immune modulating therapies such as anti-TNF-alpha antibodies, anti-CD4 antibodies, interleukin-10 and interferon have been encouraging but large scale studies are still awaited before the effect and the spectra of side-effects can be fully evaluated. The aim of this chapter is to summarize the present knowledge of medical treatment of active Crohn's disease and to point towards the directions of new therapeutic options.

Gastrointestinal drugs

Various drugs are commonly used for the many gastrointestinal problems that are routinely seen in dogs and cats. Many of these drugs are briefly reviewed in this article. Anecdotal as well as documented findings are provided that will hopefully allow the clinician to use them wisely and effectively in the many clinical situations that arise daily. Emetics, although not used for gastrointestinal problems, are also reviewed because of their obvious connection with the gastrointestinal tract.

Oral budesonide as maintenance therapy in Crohn's disease--results of a 12-month study. Global Budesonide Study Group

BACKGROUND

Budesonide is a corticosteroid with high topical anti-inflammatory activity and low systemic activity due to rapid inactivation. We have assessed the efficacy and safety of an oral controlled ileal release (CIR) preparation of budesonide for maintenance of remission in patients with ileal or ileocaecal Crohn's disease.

METHODS

In a double-blind, multicentre trial, 75 patients in clinical remission (Crohn's Disease Activity Index, CDAI, < or = 150) were randomly assigned to receive placebo, budesonide 3 mg or budesonide 6 mg daily for 12 months. Trial drugs were given at a fixed dose and without concomitant medication. The primary outcome measure was relapse, defined as a CDAI > 150 together with an increase of at least 60 units from entry. A patient was also considered to have a relapse if withdrawn from the study due to clinical deterioration, whether or not a CDAI value could be calculated at that time.

RESULTS

There were no statistically significant differences in the relapse rate at any time-point throughout the study. By 12 months the proportion of patients having relapsed were 48, 46 and 60% in those patients treated with budesonide 6 mg, 3 mg and placebo, respectively (N.S.). Treatments were well tolerated, and the proportion of patients with suppressed adrenal function (according to predetermined criteria) were 50% (6 mg), 26% (3 mg) and 17% (placebo) (P = 0.096).

CONCLUSIONS

In the present study, relapse rate and time to relapse were similar in the patients treated with budesonide CIR, 6 mg daily or 3 mg daily or with placebo, throughout 12 months. This is in contrast to the two previous trials with identical design, where a significant effect of budesonide CIR in prolonging the median time to relapse was found. Possible reasons for the negative results of the present study include small sample size, and the fact that there was a high placebo response.

The use of oral topically acting glucocorticosteroids in the treatment of inflammatory bowel disease

Glucocorticosteroids are the mainstay of treatment of active Crohn's disease and ulcerative colitis. These drugs however carry important cosmetic short-term side effects and when used long-term they induce severe irreversible complications. Topically acting glucocorticosteroids, especially budesonide, have been designed to achieve local effect at the site of inflammation without systemic effects of the drug. The first results of clinical trials are promising and budesonide has been shown to have an improved safety with almost comparable efficacy in comparison with prednisolone. The optimal enema dose seems to be 2 mg/100 ml at night whereas 9 mg o.m. is the optimal dose to treat ileal or right ileocolonic Crohn's disease. Topically acting GCS, like standard GCS are not effective for maintenance of remission of Crohn's disease or recurrence prevention after resection of the involved Crohn's segment.

Inflammatory bowel disease and osteoporosis

The relation between inflammatory bowel disease (IBD) and osteoporosis has received increasing attention during the past decade. The prevalence of low bone mass in patients with IBD has been reported to be more than 50%. The development of a quick non-invasive method to diagnose osteoporosis (dual-energy X-ray absorptiometry) provides a practical tool to identify the patient who needs special attention. The aetiology of the bone disease in patients with IBD has still not been elucidated, but corticosteroids may play a major role. Studies on the prevention/treatment of IBD-related osteoporosis are scarce. In a single uncontrolled study hormone replacement therapy proved effective in preventing bone loss in peri- and post-menopausal women with IBD. A placebo-controlled study showed that supplementation with calcium and vitamin D prevents bone loss in patients with Crohn's disease. The present paper reviews our current knowledge on the mechanisms and epidemiology of IBD-related bone disease.

Review article: Drug development in inflammatory bowel disease: budesonide--a model of targeted therapy

The use of non-specific anti-inflammatory drugs such as the glucocorticoids is the foundation of medical therapy for inflammatory bowel disease. Although conventional steroid drugs are highly effective, their use is associated with the adverse effects of Cushing's syndrome. However, the therapeutic index of these drugs can be improved by chemical modification of the steroid nucleus and the use of new drug delivery systems that target the bowel wall as the pharmacokinetic compartment of interest. Budesonide is a novel glucocorticoid compound that illustrates the potential of this approach to identify effective and safe new treatments. Regional therapy for inflammatory bowel disease is an important pharmacological concept for the future development of the new glucocorticoids and other classes of drugs.

Oral budesonide is as effective as oral prednisolone in active Crohn's disease. The Global Budesonide Study Group

BACKGROUND

The use of corticosteroids in active Crohn's disease often becomes limited by side effects. Budesonide is a potent corticosteroid with low systemic bioavailability due to an extensive first pass liver metabolism.

AIMS

To compare the efficacy and safety of two dosage regimens of budesonide and prednisolone in patients with active Crohn's disease affecting the ileum and/or the ascending colon.

PATIENTS AND METHODS

One hundred and seventy eight patients were randomised to receive budesonide controlled ileal release (CIR) capsules 9 mg once daily or 4.5 mg twice daily, or prednisolone tablets 40 mg once daily. The treatment period was 12 weeks. The primary efficacy variable was clinical remission, defined as a Crohn's Disease Activity Index (CDAI) of 150 or less.

RESULTS

After eight weeks of treatment, remission occurred in 60% of patients receiving budesonide once daily or prednisolone and in 42% of those receiving budesonide twice daily (p = 0.062). The presence of glucocorticoid associated side effects was similar in all groups; however, moon face was more common in the prednisolone group (p = 0.0005). The highest frequency of impaired adrenal function, as measured by a short ACTH test, was found in the prednisolone group (p = 0.0023).

CONCLUSIONS

Budesonide CIR, administered at 9 mg once daily or 4.5 mg twice daily, is comparable to prednisolone in inducing remission in active Crohn's disease. The single dose administration is as promptly effective as prednisolone and represents a simpler and safer therapeutic approach, with a considerable reduction in side effects.

[Steroid-induced myopathy in left-sided ulcerative colitis. Successful treatment and continued therapy with the topical steroid budesonide]

BACKGROUND

Glucocorticoids are an effective treatment of ulcerative colitis. The occurrence of steroid side effects depends on dosage and duration of steroid treatment. It may be a high as 80%. A rare side effect of glucocorticoid therapy is steroid induced myopathia. There exists an acute and a chronic form of steroid induced myopathia. Chronic steroid myopathia affects mainly the proximal musculature of the lower and upper extremities and leads to proximal muscle weakness. Histologically, an atrophy of type IIb-muscle fibers can be found. Chronic steroid myopathia occurs after prolonged treatment with higher doses of glucocorticoids.

CASE REPORT

The case report describes a 25 year old male patient with left-sided ulcerative colitis who developed chronic steroid myopathia after several months of glucocorticoid treatment. After switching from systemic steroids to budesonide the symptoms of myopathia disappeared. Left-sided ulcerative colitis remained in remission.

CONCLUSION

The case documents the disappearance of a severe steroid side effect after switching from a systemic steroid to budesonide.

Budesonide, a locally acting steroid, prevents graft rejection in a rat model of intestinal transplantation

BACKGROUND

The requirement for potent systemic immunosuppression to prevent intestinal graft rejection has resulted in high rates of infection and post-transplant lymphoproliferative disease. Budesonide (BUD) is a locally acting steroid that is almost completely metabolized during its first pass through the intestinal wall and liver. The present study examined whether BUD could prevent small bowel allograft rejection without causing the adverse systemic effects associated with prednisolone.

METHODS

Orthotopic Brown Norway to Lewis rat small bowel allotransplants were randomly assigned to treatment with low-dose BUD (0.1 mg/kg/day, p.o.) and high-dose BUD (1.0 mg/kg/day, p.o.) with and without cyclosporine (CsA; 2 mg/kg/day s.c.). The following parameters were assessed: allograft survival, recipient plasma adrenocorticotrophic hormone (ACTH) levels, recipient adrenal, splenic and thymic weights, recipient CsA levels, and graft histopathology.

RESULTS

Low- and high-dose BUD alone did not prolong graft survival compared with the untreated group (9.1+/-0.4 days vs. 11+/-0.8 days vs. 9.7+/-0.4 days, respectively). However, when low-dose BUD and high-dose BUD were given in combination with CsA, the mean graft survival times were prolonged to 27.6+/-5.3 and 36.6+/-8.0 days, respectively (P<0.01). ACTH levels, adrenal weights, and thymic weights were not significantly different in the treatment and control groups receiving intestinal transplants.

CONCLUSIONS

BUD enhances the immunosuppressive effects of CsA and prolongs small bowel allograft survival in rats without inhibiting normal ACTH release. These data suggest that BUD may be a useful immunosuppressive agent for clinical intestinal transplantation.

Inflammatory bowel disease in the elderly. Practical treatment guidelines

Although Crohn's disease and ulcerative colitis were initially described in young adults, it has become increasingly apparent that inflammatory bowel disease (IBD) affects the elderly, with the new onset of disease occurring well into the seventh and eighth decades of life. The diagnosis of IBD in the elderly may be difficult because it can be easily confused with infectious, ischaemic and drug-related processes, as well as with diverticulitis and carcinoma. Although medical treatment for IBD is similar in the young and the elderly, consideration must be given to comorbid illnesses in the older patient. Topical agents should be used as first-line therapy for patients with distal colonic disease. In patients with more proximal involvement, oral mesalazine or sulfasalazine should be used for maintenance therapy, with corticosteroids being reserved for patients with active disease. Metronidazole is particularly efficacious in patients with colonic Crohn's disease. Finally, immunomodulators can be helpful in patients who are steroid-dependent or refractory to the therapies noted above. This article reviews and outlines practical treatment guidelines for the older patient with IBD.

Inflammatory bowel disease management. Some thoughts on future drug developments

This article is intended to stimulate thought and focus on those areas where we feel advances in drug therapy for inflammatory bowel disease may occur. It is not an extensive review of current practice, although this is considered where it is thought to be pertinent to future developments. There are several excellent reviews of current practice which we do not attempt to repeat, nor do we give a comprehensive set of references, but cite well referenced reviews where necessary. New therapeutic developments should ideally stem from an understanding of the cause of pathogenesis of a condition; alternatively, established therapies may be modified or used as a basis for progress. Since the causes of both ulcerative colitis and Crohn's disease remain unknown, most forward thinking on drug development must come from current practice, but remain open to novel approaches. Our thoughts on possible future treatments for inflammatory bowel disease are somewhat selective, and because of their speculative nature are unlikely to coincide with those of others-only the future will reveal genuine advances as they become incorporated into established practice.

A dose-ranging study of azathioprine pharmacokinetics after single-dose administration of a delayed-release oral formulation

6-Mercaptopurine and its prodrug azathioprine are an effective treatment for inflammatory bowel disease, but widespread use has been limited by concern about toxicity. Ileocolonic delivery of azathioprine as a 50-mg delayed-release oral capsule has been shown to decrease bioavailability, thus potentially decreasing toxicity. This study aimed to determine the bioavailability and pharmacokinetic parameters of delayed-release oral azathioprine capsules at doses of 200 mg, 400 mg, and 600 mg relative to 100 mg of standard oral azathioprine tablets. Thirty healthy human volunteers each received delayed-release oral azathioprine at one of the three doses (n = 10 for each group). All participants also received a 100-mg tablet of standard oral azathioprine. Plasma concentrations of 6-mercaptopurine were determined by high-pressure liquid chromatography. The relative bioavailabilities of 6-mercaptopurine after ileocolonic azathioprine administration via delayed-release oral capsules at doses of 200 mg, 400 mg, and 600 mg (means of 15%, 15%, and 12%, respectively) were all significantly less than 100% compared with standard oral azathioprine at a 100-mg dose. Ileocolonic delivery of azathioprine by a delayed-release oral capsule formulation at doses up to 600 mg considerably reduces 6-mercaptopurine bioavailability, relative to standard oral azathioprine tablets. The therapeutic potential of this ileocolonic delivery formulation, which can limit toxicity by local delivery of azathioprine, should be investigated in patients with inflammatory bowel disease.

Does self-administration of a quality of life index for inflammatory bowel disease change the results?

We assessed the effect of self-administration of a disease-specific health-related quality of life instrument, the Inflammatory Bowel Disease Questionnaire (IBDQ), on score results. Patients were assessed at two visits in two tertiary centers. "Experienced" patients (N = 31) with Crohn's disease had previously completed the IBDQ several times while "novices" (N = 37) with Crohn's disease or ulcerative colitis had no prior exposure to the IBDQ. At each visit a self-administered IBDQ followed by a nurse-administered IBDQ (score range, 1-7; absolute score range, 32-224) and disease activity were assessed. At visit 1, the mean rates of discrepant responses between nurse and self-administered scores were 24 +/- 15% in experienced patients and 34 +/- 17% in novice patients (p = 0.018), which fell to 21 +/- 16 and 23 +/- 10%, respectively, by visit 2 (p = NS). However, discrepancy rates were not significantly different between novice and experienced patients when adjusted by center. Discrepancies occurred randomly in all 32 IBDQ items. Eighty percent of all discrepant responses differed by only one grade of a seven-point Likert scale. Baseline self-administered scores for all patients were 4.80 +/- 1.24 (absolute score, 153.0 +/- 39.9). Mean score differences at each visit (nurse minus self) were very small, ranging from 0.029 to 0.136, and would not be considered clinically important. Intraclass correlation coefficients between the nurse and self-administered IBDQ and the four dimensional scores were > or = 0.97 by visit 2, indicating excellent concordance and minimal observer error. Mean changes in score over time were of comparable magnitude for both self (0.320 +/- 0.819) and nurse (0.260 +/- 0.831) assessments. We conclude that the IBDQ may be reliably used as a self-administered instrument in clinical trials.

Newer treatments for inflammatory bowel disease

Despite intense investigative efforts, the causes of ulcerative colitis and Crohn's disease remain elusive. The mainstay of medical therapy focuses on inhibition of the effects of the inflammatory mediators operant in inflammatory bowel disease because the causes of these two chronic disorders are unknown. During recent years, the physician's armamentarium for medical treatment of inflammatory bowel disease has increased substantially. In this article, the current standard medical therapies available for treatment of patients with inflammatory bowel disease are reviewed along with their efficacy; the side effects and status of other investigative drugs also are reviewed.

Budesonide prolongs time to relapse in ileal and ileocaecal Crohn's disease. A placebo controlled one year study

BACKGROUND AND AIMS

To evaluate the efficacy and safety of the topical corticosteroid budesonide, given in an oral controlled release formulation for maintenance of remission in patients with ileal and ileocaecal Crohn's disease (CD).

PATIENTS AND METHODS

Out of 176 patients with active CD who had achieved remission (CD activity index score < or = 150) after 10 weeks' treatment with either budesonide or prednisolone, 90 were randomised to continue with once daily treatment of 6 mg budesonide, or 3 mg budesonide or placebo for up to 12 months in a double blind, multicentre trial. Time to symptomatic relapse was calculated using Kaplan-Meier estimates. Morning plasma cortisol was measured at clinic visits and a corticotropin stimulation test was performed after three months of treatment.

RESULTS

Thirty two patients were allocated to the 6 mg budesonide group, 31 to the 3 mg group, and 27 to the placebo group. After three months, 19 per cent of the patients in the 6 mg group had relapsed, compared with 45 per cent in the 3 mg group and 44 per cent in the placebo group (p = 0.047). The corresponding results after 12 months was 59 per cent in the 6 mg budesonide group, 74 per cent in the 3 mg group, and 63 per cent in the placebo group (p = 0.44). The median time to relapse or discontinuation was 258 days in the 6 mg group, 139 days in the 3 mg group, and 92 days in the placebo group (p = 0.021). Mean morning plasma cortisol values increased from entry in all three groups with no statistically significant differences at 12 months. All 13 patients remaining in the placebo group after three months had a normal corticotropin stimulation response, compared with 18 of 23 patients in the 6 mg, and 19 of 21 in the 3 mg budesonide groups (p = 0.14). Acne and moon face were slightly more common in the budesonide groups.

CONCLUSION

6 mg budesonide once daily is significantly more efficacious than placebo in prolonging time to relapse in CD, and causes only minor systemic side effects.

The basis of current and future therapy for inflammatory bowel disease

The majority of patients with IBD can be managed with currently available therapy, but the currently available agents do not seem to alter the natural history of the disease. An explosion of information about the immune system and the mediators of inflammation has now generated a host of new strategies that will likely benefit patients with IBD as well as patients with other chronic inflammatory and autoimmune disorders. Molecules of the immune system are being harnessed to treat disorders of the immune system. Some of these new concepts and therapies have been discussed here. Some are already in clinical trials, others have yet to be tried. As more specific immune modulators are tested in patients, it is likely that some will be effective in Crohn's disease but not ulcerative colitis and vice versa, due to, and revealing, the differences in the pathogenesis of these two diseases. The hope is that the application of these new modalities will alter the natural history of these diseases to the benefit of our patients.

Review article: the medical management of Crohn's disease

The choice of medical therapies for Crohn's disease continues to grow. Although our understanding of the mechanisms of the disease is incomplete, increasing knowledge of the pathogenesis of inflammation in general and Crohn's disease in particular allows targeting of therapies at various points in the immunoinflammatory cascade. In addition, the division of Crohn's disease into subtypes by location, aggressiveness, and the presence or absence of perianal and fistulizing disease allows the tailoring of medical therapy to the individual patient. For those patients with moderate to severe symptoms or frequent flares of disease activity, and those who have required surgical resection, maintenance therapy can substantially reduce the rate of recurrence. Despite these advances, available medical therapies for Crohn's disease remain imperfect, as evidenced by their sometimes substantial toxicities and the continued frequent need for surgery.

Ulcerative colitis in children

Chronic nonspecific ulcerative colitis remains a disease of unknown etiology, although much new information continues to be gleaned from basic research and clinical trials. In most instances, ulcerative colitis responds to medical therapy. Selecting appropriate drug therapy for a specific child depends on the extent and severity of the colitis. This article summarizes the clinical information, diagnostic studies, and approaches to management that should be considered when evaluating a child for ulcerative colitis.

Crohn's disease in children

Crohn's disease is a chronic inflammatory condition that may affect any part of the gastrointestinal system and multiple extraintestinal organs. Although its exact pathogenesis remains unknown, increasing evidence suggests an abnormality in the control of "physiologic" inflammation caused by bacterial and other antigens. Diagnosis starts with a careful history and physical examination, and confirmation rests with radiologic and histologic studies. Newer treatments are more specifically targeting the cascade of cytokine-mediated events that perpetuate inflammation.

Quality of life in inflammatory bowel disease and other chronic diseases

Health-related Quality of Life (HRQOL) status is a meaningful part of assessing the impact of disease in patients with chronic bowel disorders. It is influenced by the clinical condition but also by environmental and patient-related factors. This manuscript will highlight how HRQOL measurement can be used in chronic bowel disorders, using examples in inflammatory bowel disease, and how different types of instruments or study design may change the picture of health status.

Inflammatory bowel disease: a new assessment

The etiologies of Crohn's disease and inflammatory bowel disease remain undefined. A growing body of evidence suggests that genetic factors play at least a permissive role while a variety of initiating agents, varying from bacteria to viruses, to a vast array of inert antigens have been postulated, but clear-cut cause and effect relationships have not been established. Recently, a resurgence of interest in Mycobacteria paratuberculosis has developed. Regardless of the initiating cause, growing evidence continues to suggest an immunomodulatory role for the immune system in perpetuating the chronicity of these illnesses. Treatment approaches have been directed against possible initiating agents as well as against the elements which may establish chronicity. Thus currently antibiotics and anti-mycobacterial drugs are being utilized. A variety of anti-inflammatory and/or immunosuppressive agents, including prednisolone, cyclosporine, 6-mercaptopurine, as well as many 5-aminosalicylic acid products comprise a growing armamentarium.

Budesonide. A review of its pharmacological properties and therapeutic efficacy in inflammatory bowel disease

Budesonide is a glucocorticoid with high topical activity, but low systemic bio-availability which results in reduced systemic effects in comparison with other glucocorticoids. To date, it has been evaluated for use in patients with inflammatory bowel disease when administered either orally as a controlled ileal release formulation or rectally as an enema. In comparative trials, daily treatment with budesonide enema 2 mg/100ml for 4 weeks produced endoscopic remission or improvement in 46 to 84% of patients with active distal ulcerative colitis and/or proctitis and histological remission or improvement in 45 to 68%. In general, this regimen was effective as regimens of hydrocortisone, methylprednisolone, prednisolone or mesalazine (5-amino-salicylic acid, mesalamine) enemas, but caused less suppression of plasma cortisol levels than the other glucocorticoids. Oral treatment with controlled release budesonide 9 mg/day for 8 weeks produces clinical remission in 42 to 67% of patients with active Crohn's disease of the ileum, ileocaecal region and/or ascending colon and significantly reduces Crohn's disease activity index scores compared with baseline and placebo. Results of a quality-of-life questionnaire reflected these clinical improvements. Budesonide has similar efficacy to prednisolone. Response to budesonide is maintained after dosage tapering at 8 weeks. Compared with placebo, maintenance treatment with oral budesonide 3 or 6 mg/day increases the duration of remission in patients with Crohn's disease, but does not appear to affect the 1-year relapse rate. Thus, budesonide, administered rectally to patients with distal ulcerative colitis or proctitis or orally to patients with Crohn's disease of the ileum, ileocaecal region and/or ascending colon, is a favourable option for the treatment of acute exacerbations of inflammatory bowel disease. Because of the low incidence of adverse glucocorticoid-related effects associated with oral budesonide, it may also be a useful agent for longer term maintenance therapy if further clinical trials confirm its efficacy in this indication.

Effect of intervention in inflammatory bowel disease on health-related quality of life: a critical review

Health-related quality of life (HRQOL) is a quantitative measurement of subjective perception of health state, including emotional and social aspects. It can be reliably measured with several valid instruments. Previous reviews of the literature suggested inadequate attention to HRQOL in studies of interventions in inflammatory bowel disease.

PURPOSE

This study was undertaken to assess the current status of the quality of measurement of HRQOL in studies of inflammatory bowel disease and to review the clinical conclusions warranted by the literature.

METHOD

Medicine was searched for articles relating to ulcerative colitis, Crohn's disease, or inflammatory bowel disease and quality of life since 1981. The articles found were reviewed for citations of further articles. The adequacy of HRQOL measure was assessed and graded, and the study design was categorized to assess the strength of the literature on the whole.

RESULTS

A trend was found toward higher quality of HRQOL measurement in the period 1988 to 1994 compared with 1981 to 1987. Most of the improvement was because of increased use of standardized and multidomain but unvalidated and unpublished questionnaires for measurement.

CONCLUSIONS

Confidence in the following clinical conclusions in studies of surgical interventions in inflammatory bowel disease is limited by study design: that pelvic pouch is not inferior to ileostomy, that specific domains of HRQOL are differentially affected by different surgical procedures, and (with less confidence) that surgery is helpful in Crohn's disease. Medical studies have demonstrated that high quality HRQOL measures can be integrated into randomized, prospective trials. Clinically equivalent treatments have shown differential effects or HRQOL: 9 mg daily of budesonide is superior to 15 mg, and hydrocortisone foam enemas are superior to prednisolone. Home parenteral nutrition has received modest support, limited again by study design. It is recommended that standard tests of HRQOL be used to increase comparability of studies and to increase the quality of this literature in general. In particular the Inflammatory Bowel Disease Questionnaire, Rating Form of Inflammatory Bowel Disease Concerns, and Direct Questioning of Objectives are recommended.

Comparison of budesonide and 5-aminosalicylic acid enemas in active distal ulcerative colitis

BACKGROUND

Budesonide is a new corticosteroid with high topical anti-inflammatory activity but little systemic effect. The aim of the present study was to compare the efficacy and safety of budesonide enema (2 mg/100 mL) and 5-ASA enema (mesalazine 1 g/100 mL) given for 4 weeks in the treatment of active distal ulcerative colitis and proctitis.

METHODS

Ninety-seven patients were studied in a multicentre single-blind randomized group-comparative trial. The primary efficacy variables were endoscopy and histopathology scores obtained at 0, 2 and 4 weeks. Clinical symptoms were the secondary efficacy variables. Haematology, chemistry and adverse events were the safety variables.

RESULTS

Budesonide and 5-ASA enemas both resulted in a significant improvement in endoscopy and histopathology scores but no difference could be demonstrated between the two treatment groups. There was also a significant improvement of symptoms (number of bowel movements per day, quality of stools, presence of blood and mucus, and state of well-being) within both groups but no difference between the two treatment groups. The clinical remission rate at 4 weeks was, however, 38% for patients treated with budesonide enema but 60% for those treated with 5-ASA enema (P = 0.03). No adverse events attributed to the study drugs were recorded in either of the groups.

CONCLUSIONS

Budesonide enema 2 mg/100 mL appears to be as efficient and well-tolerated as 5-ASA enema in the treatment of active distal ulcerative colitis and proctitis.

Effects of plain and controlled-ileal-release budesonide formulations in experimental ileitis

BACKGROUND

Budesonide combines a topical anti-inflammatory activity with high first-pass hepatic extraction. This study compared the effects of plain and controlled-ileal-release (CIR) formulations of budesonide on intestinal inflammation.

METHODS

Ileitis was induced in hamsters by an intraluminal injection of trinitrobenzene sulphonic acid. Inflammation was assessed histologically and by measuring mastocytosis and myloperoxidase activity. Adrenal-pituitary axis suppression was assessed by radio-immunoassay of plasma cortisol. Animals received budesonide (200 or 800 micrograms/kg/day), CIR budesonide (200 micrograms/kg/day), or placebo.

RESULTS

Plain budesonide (200 micrograms/kg/day) did not reduce intestinal inflammation despite significantly lowered plasma cortisol levels. Plain budesonide (800 micrograms/kg/day), on the other hand, significantly reduced intestinal inflammation but further decreased plasma cortisol levels. CIR budesonide (200 micrograms/kg/day) was as effective in reducing inflammation as plain budesonide (800 micrograms/kg/day).

CONCLUSIONS

CIR budesonide was significantly more effective in reducing intestinal inflammation than plain budesonide. These results suggest that the site of delivery influences the effectiveness of budesonide and that local (topical) rather than systemic action of this compound is primarily responsible for its anti-inflammatory effect.

Budesonide-beta-D-glucuronide: a potential prodrug for treatment of ulcerative colitis

Budesonide-beta-D-glucuronide is a potentially useful orally administered prodrug for the treatment of colonic inflammatory bowel disease. Budesonide is a topically active glucocorticosteroid that exhibits low oral bioavailability (15%) in humans and laboratory animals. Oral delivery of budesonide to the inflamed tissues of the large intestine as its glucuronide prodrug should lead to locally high concentrations of active drug. Following liberation and absorption of the active drug, a large portion should be inactivated due to hepatic metabolism. Budesonide-beta-D-glucuronide was chemically stable in solutions at pHs of 1.5, 4.5, 6.5, and 7.4 at 37 degrees C. The enzymatic lability of the prodrug was assessed in luminal contents and mucosa obtained from conventional, germ-free, and colitic rats under in vitro conditions. There was a substantial change in glycosidase activity between the small intestine (proximal and distal portions) and the cecum in both conventional and colitic rat luminal contents. Luminal hydrolytic activity was low along the entire rat gastrointestinal tract of germ-free rats. Mucosal glycosidase activity was relatively low along the entire gastrointestinal tract of all three types of rats. The hydrolysis of prodrugs budesonide-beta-D-glucuronide and dexamethasone-beta-D-glucuronide in human fecal samples from patients with ulcerative colitis and normal volunteers was also measured. There were no statistically significant differences between the normal and colitic fecal samples for hydrolysis of the either prodrug or between the relative rates of hydrolysis of the two prodrugs. Hydrolysis rates of the prodrugs were about two orders of magnitude less in human fecal samples compared with those in cecal and colonic contents from the rat.

Methotrexate for the treatment of Crohn's disease. The North American Crohn's Study Group Investigators

BACKGROUND

Although corticosteroids are highly effective in improving symptoms of Crohn's disease, they may have substantial toxicity. In some patients, attempts to discontinue corticosteroids are unsuccessful.

METHODS

We conducted a double-blind, placebo-controlled multicenter study of weekly injections of methotrexate in patients who had chronically active Crohn's disease despite a minimum of three months of prednisone therapy. Patients were randomly assigned to treatment with intramuscular methotrexate (25 mg once weekly) or placebo for 16 weeks. The patients also received prednisone (20 mg once a day), which was tapered over 10 weeks unless their condition worsened. The primary outcome measure was clinical remission at the end of the 16-week trial. Remission was defined by the discontinuation of prednisone and a score of < or = 150 points on the Crohn's Disease Activity Index.

RESULTS

A total of 141 patients were randomly assigned in a 2:1 ratio to methotrexate (94 patients) or placebo (47 patients). After 16 weeks, 37 patients (39.4 percent) were in clinical remission in the methotrexate group, as compared with 9 patients (19.1 percent) in the placebo group (P = 0.025; relative risk, 1.95; 95 percent confidence interval, 1.09 to 3.48). The patients in the methotrexate group received less prednisone overall than those in the placebo group (P = 0.026). The mean (+/- SE) score on the Crohn's Disease Activity Index after 16 weeks of treatment was significantly lower in the methotrexate group (162 +/- 12) than in the placebo group (204 +/- 17, P = 0.002). The changes in quality-of-life scores and serum orosomucoid concentrations were similar. In the methotrexate group, 16 patients (17 percent) withdrew from treatment because of adverse events (including asymptomatic elevation of serum aminotransferase in 7 and nausea in 6), as compared with 1 patient (2 percent) in the placebo group.

CONCLUSIONS

In a group of patients with chronically active Crohn's disease, methotrexate was more effective than placebo in improving symptoms and reducing requirements for prednisone.

A comparison of budesonide with prednisolone for active Crohn's disease

BACKGROUND

Patients with active Crohn's disease are often treated with corticosteroids, but the treatment has many side effects. Budesonide is a potent, well-absorbed corticosteroid, but because of a high rate of first-pass metabolism in the liver, its systemic bioavailability is low.

METHODS

We conducted a randomized, double-blind, 10-week trial comparing the efficacy and safety of an oral controlled-release form of budesonide with the efficacy and safety of prednisolone in 176 patients with active ileal or ileocecal Crohn's disease (88 patients in each treatment group). The dose of budesonide was 9 mg per day for eight weeks and then 6 mg per day for two weeks. The dose of prednisolone was 40 mg per day for two weeks, after which it was gradually reduced to 5 mg per day during the last week.

RESULTS

At 10 weeks, 53 percent of the patients treated with budesonide were in remission (defined as a score < or = 150 on the Crohn's disease activity index), as compared with 66 percent of those treated with prednisolone (P = 0.12). The mean score on the Crohn's disease activity index decreased from 275 to 175 in the budesonide group and from 279 to 136 in the prednisolone group (P = 0.001). Corticosteroid-associated side effects were significantly less common in the budesonide group (29 vs. 48 patients, P = 0.003). Two patients in the prednisolone group had serious complications (one had intestinal perforation and one an abdominal-wall fistula). The mean morning plasma cortisol concentration was significantly lower in the prednisolone group than in the budesonide group after 4 weeks (P < 0.001) and 8 weeks (P = 0.02) of therapy, but not after 10 weeks.

CONCLUSIONS

Among patients with active Crohn's disease, both controlled-release budesonide and prednisolone are effective in inducing remission. In this trial, prednisolone reduced scores on the Crohn's disease activity index more, whereas with budesonide there were fewer glucocorticoid-associated side effects and less suppression of pituitary-adrenal function.