European evidence-based Consensus on the management of ulcerative colitis: Current management

Antibiotics and probiotics in inflammatory bowel disease: why, when, and how

PURPOSE OF REVIEW

To summarize recent evidence on the role of intestinal bacteria in inflammatory bowel diseases, and of antibiotics and probiotics in their treatment. The implications connected with the use of antibiotics are also examined.

RECENT FINDINGS

The hypothesis that Mycobacterium paratuberculosis could be a causative agent of Crohn's disease has not been confirmed by a large trial on symptomatic patients treated by a combination of antibiotics active against this bacterium. An increased number of adherent-invasive Escherichia coli have been found in the intestinal tissue of patients with Crohn's disease, but their role in the pathogenesis of this condition remains to be defined. The combination of metronidazole and azathioprine, associating the effects of a reduced bacterial load with immunosuppression, appears to be a therapeutic option to decrease the recurrence of postoperative Crohn's disease in high-risk patients. However, concerns are raised by the possibility that antibiotics may induce disease relapse due to Clostridium difficile infection.

SUMMARY

Recent literature provides increasing support for the use of antibiotics in Crohn's disease, although the side effects limit their long-term use. The efficacy of antibiotics in ulcerative colitis is not confirmed by the available literature, except in severe colitis. More trials are needed to support the use of probiotics as therapy in inflammatory bowel disease.

Cyclosporine treatment of steroid-refractory ulcerative colitis during pregnancy

BACKGROUND

Cyclosporine is considered a safe and effective treatment of severe steroid-refractory ulcerative colitis (UC). However, few data are available concerning its safety profile in pregnant women. We report here the experience of 5 GETAID centers.

METHODS

In a retrospective study data on patients with severe UC treated with cyclosporine during pregnancy were extracted from medical records of consecutive patients treated between 2001 and 2007.

RESULTS

Eight patients (median age 30.5 years old) were identified. At the time of flare-up the median duration of pregnancy was 11.5 weeks of gestation (range 4-25). Seven patients had pancolitis. All patients had more than 3 commonly used clinical and biological severity criteria. Three patients had severe endoscopic lesions and 5 patients had not. All patients received intravenous corticosteroids for at least 7 days before introduction of cyclosporine. Two patients received azathioprine during treatment with cyclosporine. No severe infections or other complications due to treatment were observed. Treatment was effective in 7/8 patients. One patient received infliximab due to cyclosporine therapy failure with a good outcome. No colectomy was performed during pregnancy. Seven pregnancies were conducted to term, but 1 in utero death occurred due to maternal absence of S-protein. Two newborns were premature, including 1 case of hypotrophy. No malformations were observed.

CONCLUSIONS

In our experience, treatment with cyclosporine for steroid-refractory UC during pregnancy can be considered safe and effective.

Treatment of steroid-naive ulcerative colitis

The introduction of steroid therapy by Truelove and Witts in the 1950s revolutionized the treatment of ulcerative colitis. Corticosteroids are potent inhibitors of T-cell activation and proinflammatory cytokines and still represent the mainstay of therapy of patients with ulcerative colitis. About 15% of patients are resistant to steroids, and about a quarter of patients become dependent within 1 year of therapy. Steroid-related adverse events are numerous and occur frequently. So, new steroids with low systemic absorption and better safety profile have been studied, but they show an overall lower efficacy compared with traditional steroids. A new drug-delivery system based on the use of autologous erythrocytes loaded with dexamethasone 21-phosphate has been recently developed. Several studies have demonstrated its efficacy in steroid-dependent patients leading to complete withdrawal of oral steroids and disappearance of the most steroid-related adverse events. In this review we elaborate on the role of steroids in the treatment of ulcerative colitis, focusing on the aspects related to the mechanisms of action and resistance to the steroids, and their secondary effects. Moreover, we analyse the alternatives to traditional systemic steroids such as the new steroids with low bioavailability and the steroids encapsulated into erythrocytes.

Therapeutic strategies for the management of ulcerative colitis

Induction and maintenance of remission, mucosal healing, the avoidance of surgical intervention, and decreasing the likelihood of cancer developing are the primary therapeutic goals in ulcerative colitis (UC). For the traditional therapies, 5-aminosalicylic acid (including mesalamine), corticosteroids, and thiopurines (azathioprine and mercaptopurine), there are major changes evolving in terms of formulation, patterns of use, and appreciation of long-term benefits and toxicities. The calcineurin inhibitors cyclosporin and tacrolimus, and infliximab, have recently defined, well-established roles. Preliminary supportive evidence is emerging in relation to novel antiinflammatory molecules such as curcumin, manipulation of the bacterial flora, enhancement of the mucosal barrier, and direct epithelial restoration. For patients in whom the disease is resistant to standard simple therapies, strategies are required to integrate these developing and new therapies into clinical practice. This review aims to highlight the evidence supporting new patterns of use of existing therapies and new therapies, and to devise therapeutic pathways that incorporate these new treatments. We propose how treatment might be optimized to improve the outcome in patients with mild-to-moderately active UC, chronic active UC, resistant proctitis, and fulminant UC.

Use of new once-daily 5-aminosalicylic acid preparations in the treatment of ulcerative colitis: Is there anything new under the sun?

5-aminosalicylate (5-ASA) agents remain the mainstay treatment in ulcerative colitis (UC). A number of oral 5-ASA agents are commercially available, including azobond pro-drugs, as well as delayed- and controlled-release forms of mesalazine. However, poor adherence due to frequent daily dosing and a large number of tablets has been shown to be an important barrier to successful management of patients with UC. Recently, new, once-daily formulations of mesalazine, including the unique multi-matrix delivery system and mesalazine granules, were proven to be efficacious in inducing and maintaining remission in mild-to-moderate UC, with a good safety profile comparable to that of other oral mesalazine formulations. In addition, they offer the advantage of a low pill burden and might contribute to increased long-term compliance and treatment success in clinical practice. This editorial summarizes the available literature on the short- and medium-term efficacy and safety of the new once-daily mesalazine formulations.

[Effectiveness of new, once-daily 5-aminosalicylic acid in the treatment of ulcerative colitis]

5-aminosalicylate (5-ASA) agents remain the mainstay treatment in ulcerative colitis (UC). A number of oral 5-ASA agents is commercially available, including azo-bond pro-drugs such as sulfasalazine, olsalazine and balsalazide, and delayed- and controlled-release forms of mesalazine. In addition, the effectiveness of oral therapy relies on good compliance, which may be adversely affected by frequent daily dosing and a large number of tablets. Furthermore, poor adherence has been shown to be an important barrier to successful management of patients with UC. Recently, new, once-daily formulations of mesalazine including the unique multi-matrix delivery system and mesalazine granules were proven to be efficacious in inducing and maintaining remission in mild-to-moderate UC, with a good safety profile comparable to that of other oral mesalazine formulations. In addition, they offer the advantage of low pill burden and may contribute to increased long-term compliance and treatment success in clinical practice and might potentially further contribute to a decline in the risk for UC-associated colon cancers. In this systematic review, the authors summarize the available literature on the short- and medium-term efficacy and safety of the new once-daily mesalazine formulations.

The diagnosis and treatment of Crohn's disease and ulcerative colitis

INTRODUCTION

Crohn's disease and ulcerative colitis are chronic inflammatory diseases resulting from an inappropriate immune response, in genetically susceptible individuals, to microbial antigens of commensal microorganisms. This inappropriate response is promoted by certain environmental factors. Both diseases manifest themselves primarily in the gastrointestinal tract yet can, in principle, affect all of the organ systems of the body. The purpose of this review article is to heighten awareness of these diseases among physicians whose primary clinical activities lie outside gastroenterology.

METHODS

This is not a systematic review nor a meta-analysis. It is mainly based on the guidelines of national (DGVS and DACED) and international (AGA, ACG, BSG, CCFA, ECCO) specialist societies and expert groups, as well as on important reviews and a limited number of pivotal randomized, double-blind, controlled, multicenter studies.

RESULTS

More than 300 000 people in Germany suffer from chronic inflammatory bowel diseases. The incidence and prevalence of IBD have risen in the past 10 years, particularly for Crohn's disease. Every fifth IBD patient is a child or adolescent. A better understanding of key events in the inflammatory cascade, e.g., the activation and polarization of T cells by TNF-alpha, IFN-gamma and IL-12/18 through dendritic cells, has led in recent years to the development of many new immune-modulating and biological treatments. Advanced endoscopic techniques and contrast-enhanced tomographic imaging techniques have expanded diagnostic capabilities.

CONCLUSION

A cure is still not possible, yet the opportunities for diagnosis and treatment have improved significantly. Early diagnosis is important so that patients can be referred onward for further diagnostic evaluation and appropriate treatment without delay.

An economic evaluation comparing once daily with twice daily mesalazine for maintaining remission based on results from a randomised controlled clinical trial

BACKGROUND AND AIMS

Standard practice to maintain remission in ulcerative colitis (UC) consists of daily mesalazine therapy. However, frequent dosing is associated with poor adherence and increased failure rates. The PODIUM (Pentasa™ Once Daily In UC Maintenance) randomised control trial showed 2 g once daily (OD) to be superior to twice daily (BD) dosing for maintaining remission. We sought to determine whether this alternative dosing regimen is cost-effective.

METHODS

An economic evaluation was conducted to compare costs and outcomes of OD with twice daily (BD) dosing. The main outcome considered was quality-adjusted life years (QALYs) based on health state utilities derived from the primary outcome measure, remission without relapse at 12 months defined by a UCDAI score ≤1. The economic evaluation consisted of two health states: (1) remission and (2) active UC.

RESULTS

Annual average treatment costs for OD and BD dosing were £654 (95% CI: £536-£759) and £747 (£620-£860), respectively with an average per person savings of £93 per year. Average annual costs of ancillary care for relapse for OD and BD dosing were £307 (£241-£383) and £396 (£320-£483), respectively. Treatment with OD 2 g mesalazine resulted in an incremental QALY improvement of 0.004 units, indicating that it was the dominant treatment option (i.e. improved outcomes and cost-saving). Variations in parameter estimates in the sensitivity analysis indicated that mesalazine had >0.95 probability of being cost-effective compared to BD based on accepted willingness to pay thresholds applied by the UK National Health Service.

CONCLUSIONS

Once daily 2 g mesalazine for maintaining remission in UC is cost-saving compared with 1 g twice daily. Cost-savings with 2 g once daily were achieved by differences in ancillary care attributed to higher failure rates observed with 1 g twice daily.

Serum sickness, encephalitis and other complications of anti-cytokine therapy

The introduction of biological therapies has greatly advanced the therapeutic armamentarium of the inflammatory bowel diseases Crohn's disease and ulcerative colitis. At present, three anti-tumour necrosis factor (TNF) agents (infliximab, adalimumab and certolizumab pegol) and one anti-adhesion cytokine (natalizumab) have been approved and have shown efficacy in luminal and/or fistulizing Crohn's disease and/or in ulcerative colitis. Although the overall benefit/risk ratio for the anti-TNF agents is positive, of particular concern has been the problem of immunogenicity ascribed to the formation of antibodies to these molecules. Antibody formation is associated with allergic reactions and loss of response through decreased trough serum concentrations. Ways to reduce antibody formation include maintenance therapy, the use of concomitant immunomodulators and pre-treatment with corticosteroids. Other safety concerns include the occurrence of opportunistic infections, skin manifestations, and the rare but often lethal hepatosplenic T-cell lymphoma. The alpha-4 integrin natalizumab has been associated with three cases of progressive multifocal leucoencephalopathy and was the reason for which the drug was not approved in Europe, and is available only through a specialised programme in the US. We discuss the safety aspects of the biological agents in this chapter and, where available, give ways to prevent and/or treat them.

Ulcerative colitis: current medical therapy and strategies for improving medication adherence

Ulcerative colitis (UC) is chronic inflammation of large intestine and often requires lifelong medication. Medical therapy aims to induce and maintain a clinical remission, reduce the risk of colorectal cancer and improve quality of life. Aminosalicylates are currently the first choice therapy both for the induction and the maintenance of remission in the patients with mild-to-moderate UC. For moderate-to-severe cases or those who do not respond to aminosalicylate therapy, additional treatment options including corticosteroids, immunomodulators, biological agents, cyclosporin, tacrolimus and surgery are available. Poor adherence to medication has been an important barrier to successful management of UC. Nonadherence has been associated with increased relapse rates, higher risk of colorectal cancer, poor quality of life and significantly increased healthcare costs. Therefore, improving adherence to medication is an important approach for a better care of the patients with UC. Definitive strategies are required to help the patients effectively self manage their disease and improve adherence. This review examines current medical therapy for UC, research progresses on medication adherence and the possible strategies for improving adherence in these patients.

A model of the long-term cost effectiveness of scheduled maintenance treatment with infliximab for moderate-to-severe ulcerative colitis

BACKGROUND

Infliximab (IFX) has been shown to be efficacious in moderate-severe ulcerative colitis (UC). Aim To evaluate the cost-effectiveness of a scheduled maintenance treatment (SMT) with IFX in moderate-severe UC patients.

METHODS

A Markov model was constructed to simulate the progression of a cohort of moderate-severe UC patients treated with IFX (5 mg/kg) SMT. Transitions were estimated from two phase III trials of IFX (ACT I and ACT II). Standard care, comprising immunomodulators and/or corticosteroids was used as a comparator. Two separate treatment strategies were evaluated - continued treatment in IFX responders and continued treatment in IFX patients achieving remission. The dose of IFX was estimated for a 73 kg typical UC patient in the UK. The results were calculated over 10 years using a discount rate of 3.5% for costs and outcomes. The outcome measure was quality-adjusted life years (QALYs) estimated using EQ-5D. Sensitivity analyses explored the uncertainty around the results.

RESULTS

The incremental cost effectiveness ratio (ICER) for IFX was 27,424 pounds in the responder strategy and 19,696 pounds in the remission strategy at 10 years. In sensitivity analysis, the ICER for IFX in the responder strategy ranged from 21,066 pounds to 86,322 pounds and in the remission strategy ranged from 14,728 pounds to 46,765 pounds. The model time horizon and patient body weight were important factors affecting results.

CONCLUSION

Eight-week SMT with IFX appears to be a cost-effective treatment option for adult patients suffering from moderate to severe UC.

[Update on the treatment of ulcerative colitis]

The present article reports highlights on the treatment of ulcerative colitis presented at Digestive Disease Week 2008. On the basis of the preliminary results presented, intravenous infusion of encapsulated dexamethasone may help to improve outcomes, both in terms of efficacy and toxicity in patients requiring steroids. Once-daily dosing of 5-ASA/ mesalamine is likely to be well received by patients now that this dosing regimen appears to be as effective as multiple daily dosing both in inducing remission and as maintenance therapy, whether administered orally or as a suppository. New data on the pharmacokinetics and toxicity of immunosuppressive agents and data extracted from the pivotal ACT studies (infliximab for ulcerative colitis) were presented. Among the newer agents in the pipeline, a probiotic preparation (VSL#3) may prove helpful in inducing remission in patients with ulcerative colitis associated with 5-ASA.

Review article: new drug formulations, chemical entities and therapeutic approaches for the management of ulcerative colitis

BACKGROUND

Treatment options for ulcerative colitis (UC) are expanding with the development of novel drug formulations and dosing regimens and new chemical entities. Although the goals of medical therapy for UC remain unchanged, that is to induce and to maintain remission, focus has also centred on improving patient compliance, modifying the natural course of disease and healing the mucosa.

AIM

To examine novel formulations, new chemical entities and novel therapeutic approaches to the management of UC.

METHODS

Searches for all studies related to UC treatment in Medline and abstracts from major national and international meetings published in the last 10 years.

RESULTS

5-Aminosalicylic acids (5-ASA) remain the standard first-line treatment for patients with mild to moderately active UC. New formulations with altered delivery, and new dosing regimens have demonstrated possible improvements in efficacy compared with historically available preparations and dosing patterns. Once-daily dosing, micropellet formulations,and high-dose tablets offer enhanced efficacy and improved compliance. 5-ASA is now recognized as a ligand for peroxisome proliferator activated receptor-gamma (PPAR-gamma) and it has a role as a chemo-preventive agent in long-standing UC. New colonic release corticosteroid formulations help to limit systemic toxicity; turmeric, tacrolimus and infliximab have shown promising results. New anti-inflammatory targeted therapies include an anti-CD3 antibody, selective integrin blockers, anti-IL-2 antibody and PPAR-gamma agonists.

CONCLUSION

The evolution of novel oral 5-ASA formulations and dosage regimens,and recent development of new molecules have expanded the therapeutic armamentarium of UC.

Review article: what do patients with inflammatory bowel disease want for their clinical management?

BACKGROUND

The patient's perceptions of benefits and risks of treatment differ from those of physicians, yet this topic is rarely explored in ulcerative colitis or Crohn's disease.

AIM

To present a patient's perspective on care for their colitis, to consider how patients' views will influence preliminary proposals for standards of care, and to discuss the different priorities of patients and physicians.

METHODS

Description of an individual patient's journey from diagnosis of ulcerative colitis to colectomy, compared with priorities proposed by a patient-based organization (National Association of Colitis and Crohn's disease).

RESULTS

Awareness of colitis in primary care, prompt referral, timely investigation and specialist care if admitted to hospital are shared goals of patients and physicians. Patients are generally prepared to accept higher risks from medical treatment to avoid their undesirable outcomes (especially colectomy) than physicians will on their behalf. There has been little systematic study of this disparity in ulcerative colitis. Under-reporting the symptom burden, tolerance of treatment side effects, substantial lifestyle changes and willingness to explore any treatment options are characteristic coping strategies. Physicians should be alert to coping strategies, with a willingness to seek second opinions.

CONCLUSION

Perceptions of risk and benefit differ between patients and physicians, and recognition of this difference is a starting point for difficult clinical decision-making.