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Kuenzig ME, Rezaie A, Kaplan GG, Otley AR, Steinhart AH, Griffiths AM, Benchimol EI, Seow CH. Budesonide for the Induction and Maintenance of Remission in Crohn's Disease: Systematic Review and Meta-Analysis for the Cochrane Collaboration. J Can Assoc Gastroenterol 2018; 1:159-173. [PMID: 30656288 PMCID: PMC6328928 DOI: 10.1093/jcag/gwy018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Budesonide is an oral glucocorticoid designed for the treatment of inflammatory bowel disease (IBD) that may reduce systemic adverse events (AEs). This review examined the efficacy and safety of budesonide for the induction and maintenance of clinical remission in Crohn’s disease (CD). Methods MEDLINE, EMBASE, other electronic databases, reference lists and conference proceedings were searched to November 2017 to identify randomized controlled trials of budesonide. Outcomes were the induction and maintenance of remission at eight weeks and one year, respectively, as well as corticosteroid-related AEs and abnormal adrenocorticotropic hormone (ACTH) tests. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were estimated using random effects models. Results Thirteen induction and 10 maintenance trials were included. Budesonide 9 mg/day was more effective than placebo (RR 1.93; 95% CI, 1.37–2.73; GRADE: moderate) but less effective than conventional steroids (RR 0.85; 95% CI, 0.75–0.97; GRADE: moderate) to induce remission. Corticosteroid-related AEs occurred less often with induction doses of budesonide than steroids (RR 0.64; 95% CI, 0.54–0.76; GRADE: moderate); budesonide did not increase AEs relative to placebo (RR 0.97; 95% CI, 0.76–1.23; GRADE: moderate). Budesonide 6 mg/day was not different from placebo for maintaining remission (RR 1.13; 95% CI, 0.94–1.35; GRADE: moderate). Both induction (GRADE: low for 3 mg/day, moderate for 9 mg/day) and maintenance budesonide treatment (GRADE: very low for 3 mg/day, low for 6 mg/day) increased the risk of an abnormal ACTH test compared with placebo, but less than conventional steroids (GRADE: very low for both induction and maintenance). Conclusion For induction of clinical remission, budesonide was more effective than placebo, but less effective than conventional steroids. Budesonide was not effective for the maintenance of remission. Budesonide was safer than conventional steroids, but the long-term effects on the adrenal axis and bone health remain unknown.
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Affiliation(s)
- M Ellen Kuenzig
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology & Nutrition, Children’s Hospital of Eastern Ontario, Ontario, Ottawa, Canada
| | - Ali Rezaie
- Department of Medicine, Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Anthony R Otley
- Division of Gastroenterology, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Hillary Steinhart
- Department of Medicine, Division of Gastroenterology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne Marie Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric I Benchimol
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology & Nutrition, Children’s Hospital of Eastern Ontario, Ontario, Ottawa, Canada
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Correspondence: Cynthia H. Seow, 3280 Hospital Drive NW, TRW building, Rm 6D18, Calgary, AB, T2N 4Z6, Canada, e-mail
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Leitner GC, Vogelsang H. Pharmacological- and non-pharmacological therapeutic approaches in inflammatory bowel disease in adults. World J Gastrointest Pharmacol Ther 2016; 7:5-20. [PMID: 26855808 PMCID: PMC4734954 DOI: 10.4292/wjgpt.v7.i1.5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 12/14/2015] [Accepted: 01/08/2016] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBDs) are a group of chronic inflammatory conditions mainly of the colon and small intestine. Crohn's disease (CD) and ulcerative colitis (UC) are the most frequent types of IBD. IBD is a complex disease which arises as a result of the interaction of environmental, genetic and immunological factors. It is increasingly thought that alterations of immunological reactions of the patients to their own enterable bacteria (microfilm) may contribute to inflammation. It is characterized by mucosal and sub mucosal inflammation, perpetuated by infiltration of activated leukocytes. CD may affect the whole gastrointestinal tract while UC only attacks the large intestine. The therapeutic goal is to achieve a steroid-free long lasting remission in both entities. UC has the possibility to be cured by a total colectomy, while CD never can be cured by any operation. A lifelong intake of drugs is mostly necessary and essential. Medical treatment of IBD has to be individualized to each patient and usually starts with anti-inflammatory drugs. The choice what kind of drugs and what route administered (oral, rectal, intravenous) depends on factors including the type, the localization, and severity of the patient's disease. IBD may require immune-suppression to control symptoms such as prednisolone, thiopurines, calcineurin or sometimes folic acid inhibitors or biologics like TNF-α inhibitors or anti-integrin antibodies. For both types of disease (CD, UC) the same drugs are available but they differ in their preference in efficacy between CD and UC as 5-aminosalicylic acid for UC or budesonide for ileocecal CD. As therapeutic alternative the main mediators of the disease, namely the activated pro-inflammatory cytokine producing leukocytes can be selectively removed via two apheresis systems (Adacolumn and Cellsorba) in steroid-refractory or dependent cases. Extracorporeal photopheresis results in an increase of regulatory B cells, regulatory CD8(+) T cells and T-regs Type 1. Both types of apheresis were able to induce clinical remission and mucosal healing accompanied by tapering of steroids.
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Yoshimura N, Yokoyama Y, Matsuoka K, Takahashi H, Iwakiri R, Yamamoto T, Nakagawa T, Fukuchi T, Motoya S, Kunisaki R, Kato S, Hirai F, Ishiguro Y, Tanida S, Hiraoka S, Mitsuyama K, Ishihara S, Tanaka S, Otaka M, Osada T, Kagaya T, Suzuki Y, Nakase H, Hanai H, Watanabe K, Kashiwagi N, Hibi T. An open-label prospective randomized multicenter study of intensive versus weekly granulocyte and monocyte apheresis in active crohn's disease. BMC Gastroenterol 2015; 15:163. [PMID: 26585569 PMCID: PMC4653849 DOI: 10.1186/s12876-015-0390-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/31/2015] [Indexed: 02/07/2023] Open
Abstract
Background Granulocyte and monocyte adsorptive apheresis (GMA) has shown efficacy in patients with active Crohn’s disease (CD). However, with routine weekly therapy, it may take several weeks to achieve remission. This study was performed to assess clinical efficacy and safety of intensive GMA in patients with active CD. Methods In an open-label, prospective, randomized multicentre setting, 104 patients with CD activity index (CDAI) of 200 to 450 received intensive GMA, at two sessions per week (n = 55) or one session per week (n = 49). Clinical remission was defined as a CDAI score <150. Patients in each arm could receive up to 10 GMA sessions. However, GMA treatment could be discontinued when CDAI decreased to <150 (clinical remission level). Results Of the 104 patients, 99 were available for efficacy evaluation as per protocol, 45 in the weekly GMA group, and 54 in the intensive GMA group. Remission was achieved in 16 of 45 patients (35.6 %) in the weekly GMA and in 19 of 54 (35.2 %) in the intensive GMA (NS). Further, the mean time to remission was 35.4 ± 5.3 days in the weekly GMA and 21.7 ± 2.7 days in the intensive GMA (P = 0.0373). Elevated leucocytes and erythrocyte sedimentation rate were significantly improved by intensive GMA, from 8005/μL to 6950/μL (P = 0.0461) and from 54.5 mm/hr to 30.0 mm/hr (P = 0.0059), respectively. In both arms, GMA was well tolerated and was without safety concern. Conclusions In this study, with respect to remission rate, intensive GMA was not superior to weekly GMA, but the time to remission was significantly shorter in the former without increasing the incidence of side effects. UMIN registration # 000003666. Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0390-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Naoki Yoshimura
- Department of internal medicine, Division of IBD, Tokyo Yamate Medical Centre, Tokyo, Japan.
| | - Yoko Yokoyama
- Division of Internal Medicine, Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Hyogo, Japan.
| | - Katsuyoshi Matsuoka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Hiroki Takahashi
- Department of General Medicine, National Hospital Organization, Sendai Medical Centre, Miyagi, Japan.
| | - Ryuichi Iwakiri
- Division of Gastroenterology, Department of Internal Medicine, Saga Medical School, Saga, Japan.
| | - Takayuki Yamamoto
- Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Mie, Japan.
| | - Tomoo Nakagawa
- Department of Gastroenterology and Hepatology, Chiba University Hospital, Chiba, Japan.
| | - Takumi Fukuchi
- Department of Gastroenterology and Hepatology, Osakafu Saiseikai Nakatsu Hospital, Osaka, Japan.
| | - Satoshi Motoya
- IBD Center, Sapporo Kosei General Hospital, Hokkaido, Japan.
| | - Reiko Kunisaki
- Inflammatory Bowel Centre, Yokohama City University Medical Centre, Kanagawa, Japan.
| | - Shingo Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saitama Medical Centre, Saitama Medical University, Saitama, Japan.
| | - Fumihito Hirai
- Department of Gastroenterology Fukuoka University Chikushi Hospital, Fukuoka, Japan.
| | - Yoh Ishiguro
- Department of Gastroenterology and Hematology, Hirosaki National Hospital, Aomori, Japan.
| | - Satoshi Tanida
- Department of Gastroenterology and Metabolism, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan.
| | - Sakiko Hiraoka
- Department of Gastroenterology and Hepatology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan.
| | - Keiichi Mitsuyama
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Centre, Kurume University School of Medicine, Fukuoka, Japan.
| | - Shunji Ishihara
- Department of Internal Medicine II, Faculty of Medicine, Shimane University, Izumo, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan.
| | - Michiro Otaka
- Division of Gastroenterology, Kobari General Hospital & Juntendo University, Chiba, Japan.
| | - Taro Osada
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan.
| | - Takashi Kagaya
- Department of Gastroenterology, Kanazawa University Hospital, Ishikawa, Japan.
| | - Yasuo Suzuki
- Internal Medicine, Toho University Sakura Medical Centre, Chiba, Japan.
| | - Hiroshi Nakase
- Department of Gastroenterology and Endoscopic Medicine, Kyoto University Hospital, Kyoto, Japan.
| | - Hiroyuki Hanai
- Centre for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Shizuoka, Japan.
| | - Kenji Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | | | - Toshifumi Hibi
- Kitasato Institute Hospital, Centre for Advanced IBD Research and Treatment, Kitasato University, 108-8642 Minato-ku, Tokyo, Japan.
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Rezaie A, Kuenzig ME, Benchimol EI, Griffiths AM, Otley AR, Steinhart AH, Kaplan GG, Seow CH. Budesonide for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2015; 2015:CD000296. [PMID: 26039678 PMCID: PMC10613338 DOI: 10.1002/14651858.cd000296.pub4] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Corticosteroids are commonly used for the induction of remission in Crohn's disease. However, traditional corticosteroids can cause significant adverse events. Budesonide is an alternative glucocorticoid with limited systemic bioavailability. OBJECTIVES The primary objective was to evaluate the efficacy and safety of oral budesonide for the induction of remission in Crohn's disease. SEARCH METHODS The following electronic databases were searched up to June 2014: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane IBD/FBD Group Specialised Trial Register, and ClinicalTrials.gov. Reference lists of articles, as well as conference proceedings were manually searched. SELECTION CRITERIA Randomised controlled trials comparing budesonide to a placebo or active comparator were considered for inclusion. DATA COLLECTION AND ANALYSIS Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Methodological quality was assessed using the Cochrane risk of bias tool The overall quality of the evidence supporting the outcomes was evaluated using the GRADE criteria. Meta-analysis was performed using RevMan 5.3.5 software. The primary outcome was induction of remission (defined by a Crohn's disease activity index (CDAI) < 150) by week 8 to 16 of treatment. Secondary outcomes included: time to remission, mean change in CDAI, clinical, histological or endoscopic improvement, improvement in quality of life, adverse events and early withdrawal. We calculated the relative risk (RR) and corresponding 95% confidence intervals (CIs) for each dichotomous outcome and the mean difference and corresponding 95% CI for each continuous outcome. Data were analyzed on an intention-to-treat basis. A random-effects model was used for the pooled analyses. The overall quality of the evidence supporting the primary outcomes and selected secondary outcomes was evaluated using the GRADE criteria. MAIN RESULTS Fourteen studies (1805 patients) were included: Nine (779 patients) compared budesonide to conventional corticosteroids, three (535 patients) were placebo-controlled, and two (491 patients) compared budesonide to mesalamine. Ten studies were judged to be at low risk of bias. Three studies were judged to be at high risk of bias due to open label design. One study was judged to be at high risk of bias due to selective reporting. After eight weeks of treatment, 9 mg budesonide was significantly more effective than placebo for induction of clinical remission. Forty-seven per cent (115/246) of budesonide patients achieved remission at 8 weeks compared to 22% (29/133) of placebo patients (RR 1.93, 95% CI 1.37 to 2.73; 3 studies, 379 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was moderate due to sparse data (144 events). Budesonide was significantly less effective than conventional steroids for induction of remission at eight weeks. Fifty-two per cent of budesonide patients achieved remission at week 8 compared to 61% of patients who received conventional steroids (RR 0.85, 95% CI 0.75 to 0.97; 8 studies, 750 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was moderate due to risk of bias. Budesonide was significantly less effective than conventional steroids among patients with severe disease (CDAI > 300) (RR 0.52, 95% CI 0.28 to 0.95). Studies comparing budesonide to mesalamine were not pooled due to heterogeneity (I(2) = 81%). One study (n = 182) found budesonide to be superior to mesalamine for induction of remission at 8 weeks. Sixty-eight per cent (63/93) of budesonide patients were in remission at 8 weeks compared to 42% (37/89) of mesalamine patients (RR 1.63, 95% CI 1.23 to 2.16). The other study found no statistically significant difference in remission rates at eight weeks. Sixty-nine per cent (107/154) of budesonide patients were in remission at 8 weeks compared to 62% (132/242) of mesalamine patients (RR 1.12, 95% CI 0.95 to 1.32). Fewer adverse events occurred in those treated with budesonide compared to conventional steroids (RR 0.64, 95% CI 0.54 to 0.76) and budesonide was better than conventional steroids in preserving adrenal function (RR for abnormal ACTH test 0.65, 95% CI 0.55 to 0.78). AUTHORS' CONCLUSIONS Budesonide is more effective than placebo for induction of remission in Crohn's disease. Although short-term efficacy with budesonide is less than with conventional steroids, particularly in those with severe disease or more extensive colonic involvement, the likelihood of adverse events and adrenal suppression with budesonide is lower. The current evidence does not allow for a firm conclusion on the relative efficacy of budesonide compared to 5-ASA products.
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Affiliation(s)
- Ali Rezaie
- Cedars‐Sinai Medical CenterDepartment of MedicineLos AngelesCaliforniaUSA90048
| | - M Ellen Kuenzig
- University of CalgaryDepartment of MedicineCalgaryABCanada
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Eric I Benchimol
- The Children's Hospital of Eastern OntarioCHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology & Nutrition401 Smyth RoadOttawaOntarioCanadaK1H 8L1
- University of OttawaDepartment of Pediatrics, School of Epidemiology, Public Health and Preventive MedicineOttawaOntarioCanada
| | - Anne Marie Griffiths
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & Nutrition555 University Ave.TorontoONCanadaM5G 1X8
| | - Anthony R Otley
- IWK Health CentreHead, Division of Gastroenterology5850 University AvenueHalifaxNSCanadaB3K 6R8
| | - A Hillary Steinhart
- Mount Sinai HospitalDepartment of Medicine, Division of GastroenterologyRoom 445, 600 University AvenueTorontoONCanadaM5G 1X5
| | - Gilaad G Kaplan
- University of CalgaryDepartment of MedicineCalgaryABCanada
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Cynthia H Seow
- University of CalgaryDepartment of MedicineCalgaryABCanada
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
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Filipovic BR, Filipovic BF. Psychiatric comorbidity in the treatment of patients with inflammatory bowel disease. World J Gastroenterol 2014; 20:3552-3563. [PMID: 24707138 PMCID: PMC3974522 DOI: 10.3748/wjg.v20.i13.3552] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 12/20/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis and Crohn’s disease, commonly known as inflammatory bowel disease (IBD), draw attention from specialists of various disorders, including gastroenterology, psychiatry, and radiology. The involvement of a cortical influence in the brain-gut axis as well as the interaction of the hypothalamic-pituitary-adrenal axis and the peripheral nervous system provide an initial explanation of the psychological symptoms associated with IBD. The involvement of structures the limbic system, such as the anterior cingulate cortex, the prefrontal cortex, and the amygdala, paves the way for the discovery of the mechanisms underlying depression depression, anxiety, alexithymia, personality traits, and other psychological impairments following the onset of IBD. Psychiatric therapy in IBD patients is almost as important as the gastroenterological approach and consists of pharmacological treatment and psychotherapy. Neither of the available psychiatric treatment methods is considered the golden standard because both methods have side effects, and psychotropic medication can provoke the worsening of IBD symptoms. Thus, both approaches must be applied with awareness of the possibility of side effects. We suggest that psychiatrists and gastroenterologists work together to reach a consensus on IBD therapy to ensure success and to reduce side effects and relapse to the lowest possible rates.
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Comparative effectiveness of medical interventions in adults versus children. J Pediatr 2010; 157:322-330.e17. [PMID: 20434730 DOI: 10.1016/j.jpeds.2010.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 01/15/2010] [Accepted: 02/09/2010] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To estimate the comparative effectiveness of medical interventions in adults versus children. STUDY DESIGN We identified from the Cochrane Database of Systematic Reviews (Issue 1, 2007) meta-analyses with data on at least 1 adult and 1 pediatric randomized trial with binary primary efficacy outcome. For each meta-analysis, we calculated the summary odds ratio of the adult trials and the pediatric trials, respectively; the relative odds ratio (ROR) of the adult versus pediatric odds ratios per meta-analysis; and the summary ROR across all meta-analyses. ROR <1 means that the experimental intervention is more unfavorable in children than adults. RESULTS Across 128 eligible meta-analyses (1051 adult and 343 pediatric trials), the summary ROR did not show a statistically significant difference between adults and children (0.96; 95% confidence intervals, 0.86 to 1.08). However, in all meta-analyses except for 1, the individual ROR's 95% confidence intervals could not exclude a relative difference in efficacy over 20%. In two-thirds, the relative difference in observed point estimates exceeded 50%. Nine statistically significant discrepancies were identified; 4 of them were also clinically important. CONCLUSIONS Treatment effects are on average similar in adults and children, but available evidence leaves large uncertainty about their relative efficacy. Clinically important discrepancies may occur.
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Devlin SM, Panaccione R. Evolving inflammatory bowel disease treatment paradigms: top-down versus step-up. Med Clin North Am 2010; 94:1-18. [PMID: 19944795 DOI: 10.1016/j.mcna.2009.08.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Crohn disease (CD) and ulcerative colitis (UC) comprise a group of inflammatory disorders of the gastrointestinal tract that can vary in severity of disease, anatomic extent of inflammation, presence and nature of extraintestinal manifestations, and response to therapeutic approaches. There have been attempts to classify CD based on the location and behavior of disease. Advances in understanding of genetic susceptibility to inflammatory bowel disease (IBD) suggest that CD and UC may represent a continuum of overlapping disorders. This has led to an attempt to classify IBD on clinical, molecular, and serologic grounds. Differences in clinical, genetic, and immunologic profiles may require more targeted, refined treatment approaches to help clinicians make decisions regarding recently introduced biologic agents. This article provides an overview of the current approaches to therapy for CD and UC and focuses on the evidence supporting the rationale for changing paradigms in the management of IBD, including mucosal healing as an end point and earlier use of immunosuppressive and biologic agents, particularly in CD (so-called top-down therapy).
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Affiliation(s)
- Shane M Devlin
- Division of Gastroenterology, Inflammatory Bowel Disease Clinic, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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8
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Evolving inflammatory bowel disease treatment paradigms: top-down versus step-up. Gastroenterol Clin North Am 2009; 38:577-94. [PMID: 19913203 DOI: 10.1016/j.gtc.2009.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Crohn disease (CD) and ulcerative colitis (UC) comprise a group of inflammatory disorders of the gastrointestinal tract that can vary in severity of disease, anatomic extent of inflammation, presence and nature of extraintestinal manifestations, and response to therapeutic approaches. There have been attempts to classify CD based on the location and behavior of disease. Advances in understanding of genetic susceptibility to inflammatory bowel disease (IBD) suggest that CD and UC may represent a continuum of overlapping disorders. This has led to an attempt to classify IBD on clinical, molecular, and serologic grounds. Differences in clinical, genetic, and immunologic profiles may require more targeted, refined treatment approaches to help clinicians make decisions regarding recently introduced biologic agents. This article provides an overview of the current approaches to therapy for CD and UC and focuses on the evidence supporting the rationale for changing paradigms in the management of IBD, including mucosal healing as an end point and earlier use of immunosuppressive and biologic agents, particularly in CD (so-called top-down therapy).
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Predictive value of time-intensity curves obtained with contrast-enhanced ultrasonography (CEUS) in the follow-up of 30 patients with Crohn's disease. J Ultrasound 2009; 12:151-9. [PMID: 23396614 DOI: 10.1016/j.jus.2009.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES CEUS can provide accurate quantitative estimates of intestinal wall microvascularization in Crohn's disease. We hypothesized that inflammation of the intestinal wall is correlated not with the amount of wall vascularization (study of vascularization patterns, SVP) but with the degree of wall flow during a period of time (time-intensity study, TIS). Our objective was to discover whether CEUS SPV and/or CEUS-TIS reflect(s) vascular inflammation of the intestinal wall and display(s) correlation with clinical activity of the disease at the time of the examination (T0) or at the 3- and 6-month follow-up (T3, T6). MATERIALS AND METHODS 30 patients with Crohn's disease (12 men, 18 women, mean age: 41.96 years; treatment: 5-ASA (n = 8), steroids (n = 13), anti-TNF (n = 7), azathioprine (n = 2) were studied with CEUS SPV and CEUS-TIS and followed for at least 6 months. The sonographic examinations were performed with SonoVue (BR1, Bracco) and a dedicated scanner (TECHNOS MPX, Esaote) equipped with software for calculation of time-intensity curves. Four vascular patterns (1: vascularization of the entire wall; 2: vascularization of >50% of the wall; 3: flow exclusively within the submucosal layer; 4: no signal). The semiquantitative analysis consisted in measurement of the area under the curve (AUC) (cut-off between active and inactive disease, 15), mean intesnity (IMA) (cut-off = 10). Each examination (180 s) was digitally recorded and analyzed. RESULTS T0: cDAI <150 in 22 pts; cDAI > 150 in 8; T3: 22 pts. with cDAI<150, 8 with cDAI >150. At T0 CEUS SPV and CEUS-TIS both displayed low specificity, diagnostic accuracy, and negative predictive values (p = ns). At T0, CEUS SPV produced 8 true positives (TP), 15 true negatives (TN), 8 false positives (FP), 0 false negative (FN) (sensitivity: 100%; specificity: 68.2%; diagnostic accuracy: 69.5%; Positive predictive value (PPV): 100%; negative predictive value (NPV: 53.3%), and CEUS-TIS produced 6 TP, 18 TN, 4 FP, 2 FN (sensitivity 75%; specificity: 81.8%; diagnostic accuracy: 75%; PPV: 60%; NPV: 90%). At T3, CEUS SPV produced 8 TP, 12 TN, 7 FP, 3 FN (sensitivity: 72.7%; specificity: 63.2%; diagnostic accuracy: 50%; PPV: 53.3%; NPV: 80%), and CEUS SIT produced the following results: 10 TP, 19 TN, 0 FP, 1 FN (sensitivity: 90,9%; specificity: 100%; diagnostic accuracy: 96,5%; PPV: 100%; NPV: 95%). At T3 CEUS-SVP displayed low sensitivity and low diagnostic accuracy, whereas SIT was able to predict clinical activity during follow-up in all but one case (which showed reactivation after 6 months) (p = 0.001) CONCLUSION CEUS-TIS alone was found to reflect vascular inflammation of the intestinal wall in Crohn's disease and predicted clinical activity during follow-up.
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Seow CH, Benchimol EI, Griffiths AM, Otley AR, Steinhart AH. Budesonide for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2008:CD000296. [PMID: 18646064 DOI: 10.1002/14651858.cd000296.pub3] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Corticosteroids play a key role in the induction of remission in Crohn's disease. However, corticosteroids can cause significant adverse events. Budesonide is an alternate enteral glucocorticoid with limited systemic bioavailability. OBJECTIVES The primary objective was to evaluate the efficacy and safety of oral budesonide for the induction of remission in Crohn's disease. SEARCH STRATEGY The following electronic databases were searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane IBD/FBD Group Specialised Trial Register, and ClinicalTrials.gov. Reference lists of articles, as well as conference proceedings were manually searched. Pharmaceutical companies were also contacted. SELECTION CRITERIA Randomized controlled trials comparing budesonide to a control treatment were included. The study population included patients of any age with active Crohn's disease (CDAI > 150). The primary outcome was induction of remission (CDAI < 150) by week 8 to 16 of treatment. Secondary outcomes included: time to remission, mean change in CDAI, clinical, histological or endoscopic improvement, improvement in quality of life, adverse events and early withdrawal. DATA COLLECTION AND ANALYSIS Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. A random effects model was used and studies were weighted using the DerSimonian & Laird method. Meta-analysis was performed using RevMan 4.2.10 software. MAIN RESULTS Twelve studies were included: 9 compared budesonide with conventional corticosteroids, 2 were placebo-controlled, and 1 compared budesonide with mesalamine. After 8 weeks of treatment, budesonide was significantly more effective than placebo (RR 1.96, 95% CI 1.19 to 3.23) or mesalamine (RR 1.63; 95% CI 1.23 to 2.16) for induction of remission. Budesonide was significantly less effective than conventional steroids for induction of remission (RR 0.86, 95% CI 0.76 to 0.98), particularly among patients with severe disease (CDAI > 300) (RR 0.52, 95% CI 0.28 to 0.95). Fewer adverse events occurred in those treated with budesonide compared to conventional steroids (RR 0.64, 95% CI 0.54 to 0.76) and budesonide was better able to preserve adrenal function (RR for abnormal ACTH test 0.65, 95% CI 0.55 to 0.78). AUTHORS' CONCLUSIONS Budesonide is more effective than placebo or mesalamine for induction of remission in Crohn's disease. Although short-term efficacy with budesonide is less than with conventional steroids, particularly in those with severe disease or more extensive colonic involvement, the likelihood of adverse events and adrenal suppression is lower.
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Affiliation(s)
- Cynthia H Seow
- C/O Room 445, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario, Canada, M5G 1X5.
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Akpinar HA. Therapy of mild to moderate colonic Crohn’s disease. FALK SYMPOSIUM 2008:221-231. [DOI: 10.1007/978-1-4020-6987-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Benchimol EI, Seow CH, Steinhart AH, Griffiths AM. Traditional corticosteroids for induction of remission in Crohn's disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [PMID: 18425970 DOI: 10.1002/14651858.cd006792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Historically, corticosteroids have been the most commonly used class of medication for induction of remission in Crohn's disease (CD). Corticosteroids down regulate production of inflammatory cytokines and interfere with NF-kappaB production, thereby blunting inflammatory response. OBJECTIVES The primary objective was to systematically review the efficacy and safety of traditional corticosteroids (given orally or intravenously) for induction of remission in CD. SEARCH STRATEGY The following electronic databases were searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders (IBD/FBD) Group Specialized Trial Register, and ClinicalTrials.gov. No language restrictions were applied. Reference lists of trials and review articles, as well as recent proceedings from major gastroenterology meetings were manually searched. SELECTION CRITERIA Randomized, controlled clinical trials of traditional, systemic corticosteroids for the induction of remission of active CD were included in this review. Control groups included patients receiving either placebo or 5-aminosalicylates (5-ASA). The study population included patients of any age with active CD (as defined by the study authors or validated clinical activity indices), receiving any formulation of systemically available corticosteroid by any oral or parenteral methods of delivery. The primary outcome was induction of remission of CD. Secondary outcomes included clinical response, change in mean CDAI, adverse events and the proportion of patients withdrawing due to adverse events. DATA COLLECTION AND ANALYSIS Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using Jadad's criteria. A random or fixed effects model was chosen based on an assessment of heterogeneity, and studies were weighted using the DerSimonian & Laird or the Mantel-Haenszel method accordingly. Meta-analysis was performed using RevMan 4.2.10 software. MAIN RESULTS Two studies compared corticosteroids to placebo and six studies compared corticosteroids to 5-ASA. Corticosteroids were found to be significantly more effective than placebo at inducing remission in CD (RR 1.99; 95% CI 1.51 to 2.64; P < 0.00001). Corticosteroids were found to be more effective than 5-ASA at inducing remission in studies with long follow-up duration (i.e. > 15 weeks; RR 1.65; 95% CI 1.33 to 2.03; P < 0.00001). Corticosteroids induced adverse events in a higher proportion of patients than placebo (RR 4.89; 95% CI 1.98 to 12.07; P = 0.0006), or low-dose 5-ASA (RR 2.38; 95% CI 1.34 to 4.25; P = 0.003). No difference existed in the proportion of patients experiencing adverse events when steroids were compared to high-dose 5-ASA. Steroids did not induce more study withdrawals due to adverse events than either placebo or 5-ASA. AUTHORS' CONCLUSIONS Corticosteroids are effective for induction of remission in patients with CD, particularly when used for more than 15 weeks. Although corticosteroids cause more adverse events than either placebo or low-dose 5-ASA, these adverse events did not lead to increased study withdrawal in the included studies. Further information is required to determine the optimal duration of treatment and tapering protocol to maximize the efficacy of treatment with corticosteroids. Additionally, further study is required to determine whether corticosteroids are more effective in patients with certain phenotypes or when administered intravenously.
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Affiliation(s)
- E I Benchimol
- Hospital for Sick Children, Division of Gastroenterology, Hepatology & Nutrition, 555 University Avenue, Toronto, Ontario, CANADA, M5G 1X8.
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Benchimol EI, Seow CH, Steinhart AH, Griffiths AM. Traditional corticosteroids for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2008; 2008:CD006792. [PMID: 18425970 PMCID: PMC6718222 DOI: 10.1002/14651858.cd006792.pub2] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Historically, corticosteroids have been the most commonly used class of medication for induction of remission in Crohn's disease (CD). Corticosteroids down regulate production of inflammatory cytokines and interfere with NF-kappaB production, thereby blunting inflammatory response. OBJECTIVES The primary objective was to systematically review the efficacy and safety of traditional corticosteroids (given orally or intravenously) for induction of remission in CD. SEARCH STRATEGY The following electronic databases were searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders (IBD/FBD) Group Specialized Trial Register, and ClinicalTrials.gov. No language restrictions were applied. Reference lists of trials and review articles, as well as recent proceedings from major gastroenterology meetings were manually searched. SELECTION CRITERIA Randomized, controlled clinical trials of traditional, systemic corticosteroids for the induction of remission of active CD were included in this review. Control groups included patients receiving either placebo or 5-aminosalicylates (5-ASA). The study population included patients of any age with active CD (as defined by the study authors or validated clinical activity indices), receiving any formulation of systemically available corticosteroid by any oral or parenteral methods of delivery. The primary outcome was induction of remission of CD. Secondary outcomes included clinical response, change in mean CDAI, adverse events and the proportion of patients withdrawing due to adverse events. DATA COLLECTION AND ANALYSIS Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using Jadad's criteria. A random or fixed effects model was chosen based on an assessment of heterogeneity, and studies were weighted using the DerSimonian & Laird or the Mantel-Haenszel method accordingly. Meta-analysis was performed using RevMan 4.2.10 software. MAIN RESULTS Two studies compared corticosteroids to placebo and six studies compared corticosteroids to 5-ASA. Corticosteroids were found to be significantly more effective than placebo at inducing remission in CD (RR 1.99; 95% CI 1.51 to 2.64; P < 0.00001). Corticosteroids were found to be more effective than 5-ASA at inducing remission in studies with long follow-up duration (i.e. > 15 weeks; RR 1.65; 95% CI 1.33 to 2.03; P < 0.00001). Corticosteroids induced adverse events in a higher proportion of patients than placebo (RR 4.89; 95% CI 1.98 to 12.07; P = 0.0006), or low-dose 5-ASA (RR 2.38; 95% CI 1.34 to 4.25; P = 0.003). No difference existed in the proportion of patients experiencing adverse events when steroids were compared to high-dose 5-ASA. Steroids did not induce more study withdrawals due to adverse events than either placebo or 5-ASA. AUTHORS' CONCLUSIONS Corticosteroids are effective for induction of remission in patients with CD, particularly when used for more than 15 weeks. Although corticosteroids cause more adverse events than either placebo or low-dose 5-ASA, these adverse events did not lead to increased study withdrawal in the included studies. Further information is required to determine the optimal duration of treatment and tapering protocol to maximize the efficacy of treatment with corticosteroids. Additionally, further study is required to determine whether corticosteroids are more effective in patients with certain phenotypes or when administered intravenously.
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Affiliation(s)
- E I Benchimol
- Hospital for Sick Children, Division of Gastroenterology, Hepatology & Nutrition, 555 University Avenue, Toronto, Ontario, CANADA, M5G 1X8.
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Panés J, Gomollón F, Taxonera C, Hinojosa J, Clofent J, Nos P. Crohn's disease: a review of current treatment with a focus on biologics. Drugs 2008; 67:2511-37. [PMID: 18034589 DOI: 10.2165/00003495-200767170-00005] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Crohn's disease is a debilitating and expensive disease that is growing in incidence in both developing and developed countries. While conventional therapies, such as corticosteroids and immunosuppressants, continue to play a vital role in treating this condition, it is evident that many affected individuals do not respond to therapy or develop intolerable adverse effects. The addition of modern biological therapies to the Crohn's disease armamentarium is providing a change in expectations for disease outcome. Infliximab and adalimumab are currently the only biological agents approved for induction and maintenance treatment in adults (infliximab and adalimumab) and children (infliximab) with Crohn's disease. Furthermore, infliximab has a beneficial effect on perianal fistulas. Other tumour necrosis factor (TNF)-alpha inhibitors, such as certolizumab pegol, also demonstrate promising results in adults with moderate to severe active disease. In addition, adalimumab and certolizumab pegol have shown clinical efficacy in patients who are intolerant to or lose response to infliximab, suggesting that switching between agents may allow response to be maintained over time. The primary safety concerns with TNFalpha inhibitors include increased risk of serious infection (including reactivation of tuberculosis), malignancy (particularly lymphoma) and demyelinating disease. Other agents in development include recombinant human anti-inflammatory cytokines, agents that target pro-inflammatory cytokines and granulocyte-macrophage colony-stimulating factors. Further prospective studies will provide interesting insight into different mechanisms by which factors involved in the pathophysiology of Crohn's disease can be modulated.
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Affiliation(s)
- Julián Panés
- Department of Gastroenterology, Hospital Clinic, Barcelona, Spain.
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Kozuch PL, Hanauer SB. Treatment of inflammatory bowel disease: a review of medical therapy. World J Gastroenterol 2008; 14:354-77. [PMID: 18200659 PMCID: PMC2679125 DOI: 10.3748/wjg.14.354] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 07/04/2007] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract. While a cure remains elusive, both can be treated with medications that induce and maintain remission. With the recent advent of therapies that inhibit tumor necrosis factor (TNF) alpha the overlap in medical therapies for UC and CD has become greater. Although 5-ASA agents have been a mainstay in the treatment of both CD and UC, the data for their efficacy in patients with CD, particularly as maintenance therapy, are equivocal. Antibiotics may have a limited role in the treatment of colonic CD. Steroids continue to be the first choice to treat active disease not responsive to other more conservative therapy; non-systemic steroids such as oral and rectal budesonide for ileal and right-sided CD and distal UC respectively are also effective in mild-moderate disease. 6-mercaptopurine (6-MP) and its prodrug azathioprine are steroid-sparing immunomodulators effective in the maintenance of remission of both CD and UC, while methotrexate may be used in both induction and maintenance of CD. Infliximab and adalimumab are anti-TNF agents approved in the US and Europe for the treatment of Crohn's disease, and infliximab is also approved for the treatment of UC.
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Gisbert JP, Gomollón F. Errores frecuentes en el manejo del paciente ambulatorio con enfermedad inflamatoria intestinal. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:469-86. [DOI: 10.1157/13110491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Irving PM, Gearry RB, Sparrow MP, Gibson PR. Review article: appropriate use of corticosteroids in Crohn's disease. Aliment Pharmacol Ther 2007; 26:313-29. [PMID: 17635367 DOI: 10.1111/j.1365-2036.2007.03379.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Corticosteroids are a well-established treatment for active Crohn's disease and have been widely used for decades. It has become apparent, however, that a proportion of patients either fails to respond to corticosteroids or is unable to withdraw from them without relapsing. Furthermore, their use is associated with a range of side effects, such that long-term treatment carries unacceptable risk. AIM To review the evidence regarding the appropriate use of corticosteroids in Crohn's disease, along with their side effects, safety and alternatives. METHODS To collect relevant articles, a PubMed search was performed from 1966 to November 2006 using the terms 'steroid', 'corticosteroid', 'glucocorticoid', 'prednisolone', 'prednisone', 'methylprednisolone', 'hydrocortisone', 'dexamethasone' and 'budesonide' in combination with 'Crohn(s) disease'. Relevant articles were reviewed, as were their reference lists to identify further articles. RESULTS When used correctly, corticosteroids are a highly effective, well tolerated, cheap and generally safe treatment for active Crohn' disease. Nevertheless, approximately 50% of recipients will either fail to respond (steroid-resistant) or will be steroid dependent at 1 year. Newer alternatives to corticosteroids are not, however, without risk themselves and, moreover, are not necessarily available universally. CONCLUSIONS Steroids are used widely to treat Crohn's disease, a situation that is unlikely to change in the near future. Accordingly, efforts should be made to ensure that they are used correctly and that their side effects are minimized. Reference is made to recently published guidelines and a simplified 'users guide' is presented.
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Affiliation(s)
- P M Irving
- Department of Gastroenterology, Box Hill Hospital and Monash University, Melbourne, Australia
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Affiliation(s)
- Xavier Treton
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie et Assistance Nutritive, Université Paris VII, and Service de Radiologie, Hôpital Beaujon, Clichy, France
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Abstract
The incidence of inflammatory bowel disease in patients aged 60 years and older is approximately 3.5/100,000 people/year for Crohn’s disease and 4.5/100,000 people/year for ulcerative colitis. An increased frequency of comorbidities and an increased risk of other forms of colitis in elderly patients can make the diagnosis of inflammatory bowel disease challenging. The clinical course of inflammatory bowel disease in the elderly is generally similar to that in younger patients, with primary differences noted in symptom frequency and disease location. The treatment of inflammatory bowel disease in the elderly is also generally the same as that for younger patients. Elderly patients are more likely to experience side-effects from corticosteroids and to have contraindications to immunosuppressive therapy. Surgical outcomes for inflammatory bowel disease in the elderly patient have improved over time. Outcomes and complications from surgery in the elderly population are similar to those of younger patients.
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Affiliation(s)
- Paul E Evans
- Mayo Clinic College of Medicine, Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, Mayo building E-19 B Gastroenterology, 200 First street SW, Rochester MN 55905 USA
| | - Darrell S Pardi
- Mayo Clinic College of Medicine, Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, Mayo building E-19 B Gastroenterology, 200 First street SW, Rochester MN 55905 USA
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Dinesen L, Travis S. Targeting nanomedicines in the treatment of Crohn's disease: focus on certolizumab pegol (CDP870). Int J Nanomedicine 2007; 2:39-47. [PMID: 17722511 PMCID: PMC2673818 DOI: 10.2147/nano.2007.2.1.39] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A variety of targets for therapeutic intervention are based upon advances in understanding of the immunopathogenesis of Crohn's disease. Crohn's disease is initiated by an innate immune response, which eventuates in a T-cell driven process, characterized by a T-helper cell 1 type cytokine profile. Several new treatments now focus on suppressing T-cell differentiation or T-cell inflammation. Since inflammatory bowel disease (IBD) represents a state of dysregulated inflammation, drugs that augment the anti-inflammatory response have the potential to downregulate inflammation and thereby hopefully modify the disease. Tumour necrosis factor (TNF) is a major target of research and clinical investigation. TNF has proinflammatory effects in the intestinal mucosa and is a pivotal cytokine in the inflammatory cascade. Certolizumab pegol (CDP870) is a PEGylated, Fab' fragment of a humanized anti-TNF-alpha monoclonal antibody. PEGylation increases the half-life, reduces the requirement for frequent dosing, and possibly reduces antigenicity as well. Certolizumab has been shown in Phase III trials to achieve and maintain clinical response and remission in Crohn's disease patients. It improves the quality of life. Certolizumab pegol will be indicated for moderately to severely active Crohn's disease, but it is not yet licensed in Europe or the US. It is not possible to construct an algorithm for treatment, but when compared with infliximab the two principal advantages are likely to be lower immunogenicity (as shown by anti-drug antibodies, absence of infusion reactions, and low rate of antinuclear antibodies), and a subcutaneous route of administration. These two factors may be sufficient to promote it up the pecking order of anti-TNF agents.
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Affiliation(s)
- Lotte Dinesen
- Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Simon Travis
- Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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