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Akiyama S, Steinberg JM, Kobayashi M, Suzuki H, Tsuchiya K. Pregnancy and medications for inflammatory bowel disease: An updated narrative review. World J Clin Cases 2023; 11:1730-1740. [PMID: 36969991 PMCID: PMC10037280 DOI: 10.12998/wjcc.v11.i8.1730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/14/2023] [Accepted: 02/21/2023] [Indexed: 03/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is often diagnosed during the peak reproductive years of young women. Women with active IBD around conception are at a significantly increased risk of disease relapse during pregnancy, which is associated with poor pregnancy and neonatal outcomes. Given these substantial risks, it is prudent that disease remission should ideally be achieved before conception. Unfortunately, some patients may experience a disease flare-up even if they are in a state of remission before pregnancy. Patients must continue their IBD medications to reduce the risk of disease flare and subsequent poor outcomes during the gestational and postpartum periods. When treating IBD flare-ups during pregnancy, the management is quite similar to the therapeutic approach for non-pregnant patients with IBD, including 5-aminosalicylate, steroids, calcineurin inhibitors (CNIs), and biologic therapies. While the data regarding the safety of CNIs in pregnant women with IBD is limited, the findings in our recent meta-analysis suggest that CNIs may be safer to use in those with IBD than in solid organ transplant recipients. There are several types of biologics and small-molecule therapies currently approved for IBD, and physicians should thoroughly understand their clinical benefits and safety profiles when utilizing these treatments in the context of pregnancy. This review highlights recent studies, including our systematic review and meta-analysis, and discusses the clinical advantages and safety considerations of biologics and small molecules for pregnant women with IBD.
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Affiliation(s)
- Shintaro Akiyama
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Joshua M Steinberg
- Department of Inflammatory Bowel Disease, Gastroenterology of the Rockies, Denver, CO 80027, United States
| | - Mariko Kobayashi
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Hideo Suzuki
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
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Ferretti F, Cannatelli R, Monico MC, Maconi G, Ardizzone S. An Update on Current Pharmacotherapeutic Options for the Treatment of Ulcerative Colitis. J Clin Med 2022; 11:jcm11092302. [PMID: 35566428 PMCID: PMC9104748 DOI: 10.3390/jcm11092302] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/10/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022] Open
Abstract
The main goals of Ulcerative Colitis (UC) treatment are to both induce and maintain the clinical and endoscopic remission of disease, reduce the incidence of complications such as dysplasia and colorectal carcinoma and improve quality of life. Although a curative medical treatment for UC has not yet been found, new therapeutic strategies addressing specific pathogenetic mechanisms of disease are emerging. Notwithstanding these novel therapies, non-biological conventional drugs remain a mainstay of treatment. The aim of this review is to summarize current therapeutic strategies used as treatment for ulcerative colitis and to briefly focus on emerging therapeutic strategies, including novel biologic therapies and small molecules. To date, multiple therapeutic approaches can be adopted in UC and the range of available compounds is constantly increasing. In this era, the realization of well-designed comparative clinical trials, as well as the definition of specific therapeutic models, would be strongly suggested in order to achieve personalized management for UC patients.
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Mezzina N, Campbell Davies SE, Ardizzone S. Nonbiological therapeutic management of ulcerative colitis. Expert Opin Pharmacother 2018; 19:1747-1757. [DOI: 10.1080/14656566.2018.1525361] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Nicolò Mezzina
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco – Department of Biochemical and Clinical Sciences “L. Sacco”, University of Milan, Milano, Italy
| | | | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco – Department of Biochemical and Clinical Sciences “L. Sacco”, University of Milan, Milano, Italy
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Looking for the best anti-colitis medicine: A comparative analysis of current and prospective compounds. Oncotarget 2018; 8:228-237. [PMID: 27974688 PMCID: PMC5352114 DOI: 10.18632/oncotarget.13894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/15/2016] [Indexed: 12/15/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic lifelong inflammatory disorder of the colon, which, while untreated, has a relapsing and remitting course with increasing risk of progression toward colorectal cancer. Current medical treatment strategies of UC mostly focus on inhibition of the signs and symptoms of UC to induce remission and prevent relapse of disease activity, minimizing the impact on quality of life, but not affecting the cause of disease. To date, however, there is no single reliable treatment agent and/or strategy capable of effectively controlling colitis progression throughout the patient's life without side effects, remission, or resistance. Taking into consideration an urgent need for the new colitis treatment strategies, targets and/or modulators of inflammation, we have tested current and prospective compounds for colitis treatment and directly compared their anti-colitis potency using a dextran sulfate sodium (DSS) mouse model of colitis. We have introduced a composite score - a multi-parameters comparison tool - to assess biological potency of different compounds.
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Abstract
INTRODUCTION Ulcerative colitis (UC) is a chronic inflammatory bowel disease with a relapsing-remitting course that determines significant morbidity and can associate with local complications and/or extra-intestinal manifestations. Pharmacological therapies are often required for a lifetime with possible risks of toxicity and side effects. Areas covered: Non-biological therapies (i.e. aminosalicylates, corticosteroids and immunosuppressive drugs) are widely used in UC patients for controlling the active phases of the disease and maintaining remission. Expert Opinion: Aminosalycilates have a good safety profile with a low risk of idiosyncrasic reactions. In contrast, the use of corticosteroids and immunosuppressive drugs can associate with unacceptable side effects, some of which are potentially life threatening. Mechanisms underlying the development of these side effects are not fully understood and strategies aimed to prevent them have not yet been standardized. However, clinicians should monitor the patients during therapy to recognize the adverse events at an early stage of the occurrence. New drugs that selectively target molecules involved in the amplification of the ongoing mucosal inflammation are currently under investigation. Preliminary data indicate that such compounds have better overall safety and tolerability than corticosteroids and immunosuppressive drugs.
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Affiliation(s)
- Edoardo Troncone
- a Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Giovanni Monteleone
- a Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
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Chen Y, Xue G, Liu F, Gong X. Immunosuppressive effect of extracts from leaves of Fraxinus Mandshurica Rupr. Bioengineered 2016; 8:212-216. [PMID: 27533742 DOI: 10.1080/21655979.2016.1221023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Plants provide a rich resource of medicinal material for research and development of new medicine. To discover new compounds as Immunosuppressant from plants, we evaluated the immunosuppressive effect of different fractions and particularly one compound (Calceolarioside A) that were extracted from the leaves of Fraxinus Mandshurica Rupr. The fractions and the compound were tested on the ability to reduce Immunoglobulin E (IgE) secretion by human U266 multiple myeloma cells (U266 cells) and to reduce interleukin-2 (IL-2) secretion by mouse spleen cells. Our results showed that both the butanol extract fraction and the compound of Calceolarioside A inhibited the IgE and IL-2 production in U266 cells and mouse spleen cells respectively, and no cytotoxicity was observed within the effective dose range. These results suggest that Calceolarioside A could potentially serve as an immunosuppressant.
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Affiliation(s)
- Yujuan Chen
- a School of Life Science and Technology , Changchun University of Science and Technology , Changchun , China
| | - Gang Xue
- a School of Life Science and Technology , Changchun University of Science and Technology , Changchun , China
| | - Feizhou Liu
- b Changchun Changsheng Life Sciences Limited , Changchun , China
| | - Xiuling Gong
- c Shanghai Zijiang Enterprise Group Co., LTD, Changchun Branch , Changchun , China
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Koko WS, Mesaik MA, Ranjitt R, Galal M, Choudhary MI. Immunosuppressive phenolic compounds from Hydnora abyssinica A. Braun. Altern Ther Health Med 2015; 15:400. [PMID: 26553149 PMCID: PMC4638089 DOI: 10.1186/s12906-015-0931-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 11/03/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hydnora abyssinica (HA) A. Braun is an endemic Sudanese medicinal plant traditionally used as anti-inflammatory and against many infectious diseases. However, it proved to be very rich in phenols and tannins, so the present study was undertaken to investigate the immunomodulatory potential of the whole plant ethanolic extract and its isolated compounds. METHODS Lymphocyte proliferation, chemiluminescence and superoxide reduction assays were used for immunomodulatory evaluation. While, MTT (3-(4, 5-dimethylthazol-2-yl)-2, 5-diphenyl tetrazonium bromide) test was performed on 3 T3 cell line clone in order to evaluate the cytoxicity effect of the extracts and isolated compounds of phenolic derivatives which were carried out by chromotographic techniques. RESULTS Catechin, (1), tyrosol (2) and benzoic acid, 3, 4, dihydroxy-, ethyl ester (3) compounds were isolated from HA ethanolic extract which revealed potent immunosuppressive activity against reactive oxygen species from both polymorph nuclear cells (PMNs) (45-90 % inhibition) and mononuclear cells (MNCs) (30 -65 % inhibition), T lymphocyte proliferation assay (70-93 % inhibition) as well as potent inhibitory effect against superoxide production (42-71 % inhibition) at concentrations of 6.25-100 μg/mL. Catechin (1) was found the most potent immunosuppressive agent among all constituents examined. CONCLUSION These results can support the traditional uses of H. abyssinica extracts as anti-inflammatory and immunosuppressive and further investigations of the mode of action and other pharmacological studies are highly desirable.
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Bezzio C, Furfaro F, de Franchis R, Maconi G, Asthana AK, Ardizzone S. Ulcerative colitis: current pharmacotherapy and future directions. Expert Opin Pharmacother 2014; 15:1659-70. [DOI: 10.1517/14656566.2014.925445] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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El Ashry ESH, El Tamany ESH, Abd El Fattah MED, Aly MRE, Boraei ATA, Mesaik MA, Abdalla OM, Fatima B, Jabeen A, Shukrulla A, Soomro S. Immunomodulatory properties of S- and N-alkylated 5-(1H-indol-2-yl)-1,3,4-oxadiazole-2(3H)-thione. J Enzyme Inhib Med Chem 2011; 28:105-12. [DOI: 10.3109/14756366.2011.636361] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- El Sayed H. El Ashry
- International Center for Chemical and Biological Sciences, H.E.J. Research Institute of Chemistry, Karachi University,
Karachi, Pakistan
- Chemistry Department, Faculty of Science, Alexandria University,
Alexandria, Egypt
| | | | | | - Mohamed R. E. Aly
- Chemistry Department, Faculty of Science, Suez Canal University,
Ismailia, Egypt
| | - Ahmed T. A. Boraei
- International Center for Chemical and Biological Sciences, H.E.J. Research Institute of Chemistry, Karachi University,
Karachi, Pakistan
- Chemistry Department, Faculty of Science, Suez Canal University,
Ismailia, Egypt
| | - M. Ahmed Mesaik
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, Karachi University,
Karachi, Pakistan
| | - Omer M. Abdalla
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, Karachi University,
Karachi, Pakistan
| | - Beenish Fatima
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, Karachi University,
Karachi, Pakistan
| | - Almas Jabeen
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, Karachi University,
Karachi, Pakistan
| | - Ahmed Shukrulla
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, Karachi University,
Karachi, Pakistan
| | - Samreen Soomro
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, Karachi University,
Karachi, Pakistan
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Lichtiger S. Treatment of choice for acute severe steroid-refractory ulcerative colitis is cyclosporine. Inflamm Bowel Dis 2009; 15:141-2. [PMID: 18266232 DOI: 10.1002/ibd.20363] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Simon Lichtiger
- Henry Janowitz Department of Gastroenterology, Mount Sinai Medical Center, 1755 York Ave., New York, NY 10128, USA.
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11
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Yen EF, Kane SV, Ladabaum U. Cost-effectiveness of 5-aminosalicylic acid therapy for maintenance of remission in ulcerative colitis. Am J Gastroenterol 2008; 103:3094-105. [PMID: 18775007 DOI: 10.1111/j.1572-0241.2008.02130.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Oral 5-aminosalicylic acid (5-ASA, mesalamine) is effective in inducing and maintaining remission in ulcerative colitis (UC). The relative benefits and costs of maintenance 5-ASA therapy are uncertain. Our aims were to evaluate this strategy's potential cost-effectiveness. METHODS We constructed a Markov model to compare two strategies over 2 yr: (a) no maintenance 5-ASA, with 5-ASA 4.8 g/day given for flares, (b) maintenance 5-ASA 2.4 g/day, escalated and maintained at 4.8 g/day after the first flare. In both arms, the failure to induce remission led to other treatments, as needed: prednisone, parenteral corticosteroids, cyclosporine, 6-mercaptopurine, infliximab, and colectomy. RESULTS Without maintenance 5-ASA, the mean flares per person were 1.92, and the mean cost per person was $3,402. With maintenance 5-ASA providing a relative risk of flare of 0.7 at 5-ASA cost of $198/month, flares per person decreased to 1.38 at a cost of $8,810/flare prevented. Maintenance 5-ASA increased discounted quality-adjusted life-years per person (QALYs per person) from 1.75 to 1.77 at a discounted cost of $224,000/QALY gained. The results were most sensitive to the flare risk reduction and cost of 5-ASA, the utilities of being in remission without or with 5-ASA, and the colectomy rates. At $15/month (the cost of sulfasalazine), maintenance 5-ASA cost $640/flare prevented and $16,300/QALY gained. CONCLUSION Maintenance 5-ASA therapy decreases UC flares, but its cost may be substantial, depending on society's willingness to pay. If sulfasalazine can be tolerated and yields comparable benefits, sulfasalazine maintenance therapy is likely to be cost-effective. The cost per QALY gained by 5-ASA maintenance is highly dependent on the quality of life while taking versus not taking maintenance 5-ASA, highlighting the importance of patients' preferences.
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Affiliation(s)
- Eugene F Yen
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California 94143-0538, USA
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12
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Allison J, Herrinton LJ, Liu L, Yu J, Lowder J. Natural history of severe ulcerative colitis in a community-based health plan. Clin Gastroenterol Hepatol 2008; 6:999-1003. [PMID: 18774533 DOI: 10.1016/j.cgh.2008.05.022] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 04/23/2008] [Accepted: 05/29/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We sought to evaluate long-term outcomes of patients with severe ulcerative colitis (UC) after their first hospitalization for the disease. METHODS A cohort of 656 patients hospitalized for UC during 1996 to 2004 was followed up for 9 years through 2004. Time-to-event was estimated using actuarial methods, and the proportions of those under follow-up evaluation who experienced outcomes at month 3, year 1, and year 5 were determined. Outcome measures studied were time to subsequent colectomy, rehospitalization for inflammatory bowel disease, and restarting steroid medication. We also used survival analysis to evaluate whether patient characteristics predicted the risk of rehospitalization and colectomy. RESULTS Among 656 patients initially hospitalized for severe UC, 20% (N = 129) underwent colectomy during their initial hospitalization. Of the remaining 527, a total of 95% (N = 498) were discharged on a steroid taper. At 1 year after discharge, 29% of those remaining under observation were rehospitalized for UC, and an additional 10% required colectomy. At 1 and 5 years after discharge, 34% and 26% received at least a 90-day supply of steroid in the preceding 9 months. Risk of rehospitalization and colectomy were unrelated to the patient's age, sex, or race/ethnicity. CONCLUSIONS The risk for colectomy in patients hospitalized for the first time with severe UC is 20%. In the 3 months after hospitalization the risk for colectomy is 6%. After that, risks appear to decrease proportionate to the time since initial hospitalization.
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Affiliation(s)
- James Allison
- Division of Research, Kaiser Permanente Northern California, Oakland, California 94612, USA.
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Dumortier J, Lapalus MG, Guillaud O, Poncet G, Gagnieu MC, Partensky C, Scoazec JY. Everolimus for refractory Crohn's disease: a case report. Inflamm Bowel Dis 2008; 14:874-7. [PMID: 18275074 DOI: 10.1002/ibd.20395] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Oz HS, Ebersole JL. Application of prodrugs to inflammatory diseases of the gut. Molecules 2008; 13:452-74. [PMID: 18305431 PMCID: PMC6244946 DOI: 10.3390/molecules13020452] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 02/20/2008] [Accepted: 02/21/2008] [Indexed: 12/11/2022] Open
Abstract
Oral delivery is the most common and preferred route of drug administration although the digestive tract exhibits several obstacles to drug delivery including motility and intraluminal pH profiles. The gut milieu represents the largest mucosal surface exposed to microorganisms with 1010-12 colony forming bacteria/g of colonic content. Approximately, one third of fecal dry matter is made of bacteria/ bacterial components. Indeed, the normal gut microbiota is responsible for healthy digestion of dietary fibers (polysaccharides) and fermentation of short chain fatty acids such as acetate and butyrate that provide carbon sources (fuel) for these bacteria. Inflammatory bowel disease (IBD) results in breakage of the mucosal barrier, an altered microbiota and dysregulated gut immunity. Prodrugs that are chemically constructed to target colonic release or are degraded specifically by colonic bacteria, can be useful in the treatment of IBD. This review describes the progress in digestive tract prodrug design and delivery in light of gut metabolic activities.
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Affiliation(s)
- Helieh S Oz
- Center for Oral Health Research, College of Dentistry and Department of Internal Medicine, University of Kentucky, Medical Center, 800 Rose Street, Lexington, KY 40536, USA.
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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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Mardini HE, Schwartz DA. Treatment of perianal fistula and abscess: Crohn’s and non-Crohn’s. ACTA ACUST UNITED AC 2007; 10:211-20. [PMID: 17547859 DOI: 10.1007/s11938-007-0014-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The management of perianal abscesses and fistulas is relatively straightforward in most cases and based on a sound knowledge of the anatomy of the anorectum and adherence to established medical and surgical principles. Asymptomatic fistulas should not be treated, whereas abscesses require surgical drainage under general anesthesia. Fistula treatment includes drainage of any associated sepsis and eradication of the fistula track to prevent recurrence while preserving sphincter integrity. A small percentage of anal abscesses and fistulas are complex and very challenging to manage, particularly in conditions such as rectovaginal fistulas and abscesses and/or fistulas complicating Crohn's disease. Treatment strategies in these situations rely on an accurate clinical assessment of the degree of rectal inflammation and perianal pathology. Treatment should combine aggressive medical therapy (antibiotics, immunomodulators, and anti-tumor necrosis factor antibody treatment) and minimal surgical interventions. Patients with proctitis have a significantly lower healing rate and a significantly higher complication rate with aggressive surgical interventions.
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Affiliation(s)
- Houssam E Mardini
- David A. Schwartz, MD Director, Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, 1501 TVC, Nashville, TN 37232, USA.
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Seksik P, Daniel F, Marteau P, Beaugerie L, Cosnes J. [Refractory proctitis]. ACTA ACUST UNITED AC 2007; 31:393-7. [PMID: 17483776 DOI: 10.1016/s0399-8320(07)89398-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Philippe Seksik
- Service de Gastroentérologie et Nutrition, Hôpital Saint-Antoine, Paris, France.
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Farkas S, Hornung M, Sattler C, Guba M, Steinbauer M, Anthuber M, Herfarth H, Schlitt HJ, Geissler EK. Rapamycin decreases leukocyte migration in vivo and effectively reduces experimentally induced chronic colitis. Int J Colorectal Dis 2006; 21:747-53. [PMID: 16228179 DOI: 10.1007/s00384-005-0793-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Immunosuppressive calcineurin inhibitors, like cyclosporine (CsA), can be used for the clinical management of severe ulcerative colitis. However, patients treated with CsA are at a risk for developing kidney failure and may be more susceptible to colon cancer. Furthermore, severe neurotoxicity and hypertension are common problems. To avoid the side effects of CsA, new immunosuppressive drugs to treat colitis are needed. The aim of the present study was to test the immunosuppressive mammalian target of rapamycin inhibitor rapamycin in an experimental model of chronic colitis and to compare its effectiveness with CsA. METHODS Chronic colitis was established in Balb/c mice after four feeding cycles of dextran sodium sulfate. Because leukocyte recruitment to sites of intestinal inflammation is crucial for the development of chronic colitis, intravital microscopy was used to study the effect of rapamycin and CsA on leukocyte-endothelium interactions and leukocyte extravasation. To assess the degree of colitis, histological sections were evaluated. RESULTS Both rapamycin and cyclosporine effectively reduced leukocyte sticking (>60%) in submucosal venules, as compared to controls. Furthermore, rapamycin, but not CsA, reduced (>35%) leukocyte extravasation in the mucosa. Both rapamycin and CsA treatments significantly improved the histologic inflammation score. CONCLUSION Our in vivo results demonstrate that rapamycin reduces leukocyte sticking and extravasation during chronic colitis induction and proves to be as effective as CsA at reducing experimental chronic colitis. These results support the use of rapamycin in clinical trials to avoid serious side effects of CsA therapy in chronic colitis patients.
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Affiliation(s)
- Stefan Farkas
- Department of Surgery, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany.
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Abstract
Crohn's disease is a common indication for referral to pediatric gastroenterology. While most patients with Crohn's disease respond to standard induction therapy, steroid-refractory or steroid-dependent disease is a frequently encountered problem. This review discusses the data existing in both the adult and pediatric literature for medical therapy of refractory pediatric Crohn's disease.
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Affiliation(s)
- William A Faubion
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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Freundlich M. Bone mineral content and mineral metabolism during cyclosporine treatment of nephrotic Syndrome. J Pediatr 2006; 149:383-9. [PMID: 16939753 DOI: 10.1016/j.jpeds.2006.04.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2005] [Revised: 03/23/2006] [Accepted: 04/27/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although cyclosporine (Cy) has been associated with bone loss following transplantation, its effects on bone in growing children are largely unknown. STUDY DESIGN Thirty-seven patients (2-16 years of age) with remitting nephrotic syndrome (NS), n = 16 receiving Cy for 39 +/- 27 months and n = 21 without Cy, underwent mineral metabolism and bone turnover assessment. In 28 of 37 patients, bone mineral density (BMD) was obtained while off corticosteroid therapy (Rx). RESULTS Urinary calcium (Ca), phosphate (PO(4)), and magnesium (Mg) excretion was normal, but serum Mg was lower in patients receiving Cy (1.8 +/- 0.1 v 1.95 +/- 0.2 mg/dL, P < .05). BMD Z scores were similar at the spine (-0.45 +/- 0.74 v 0.04 +/- 0.9) and femur (-0.17 +/- 0.52 v 0.38 +/- 1.28) with no Z score <-2. Serum bone-specific alkaline phosphatase was normal, and N-telopeptide of type I collagen also normal, was higher on Cy (P < .05). Cumulative prednisone exposure was similar and had no significant effect on height and BMD Z scores. Length of Cy-Rx and time elapsed from onset of NS did not correlate with BMD, height Z score, or markers of bone turnover. CONCLUSIONS In growing children with NS, during long-term Cy-Rx urinary wasting of Ca and Mg was absent and bone density was preserved.
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Siegel CA, Sands BE. Review article: practical management of inflammatory bowel disease patients taking immunomodulators. Aliment Pharmacol Ther 2005; 22:1-16. [PMID: 15963074 DOI: 10.1111/j.1365-2036.2005.02520.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Azathioprine, mercaptopurine, methotrexate, ciclosporin and tacrolimus all have their respective niches in the treatment of inflammatory bowel disease. These immunomodulators are potent and effective medications; however, they potentially have serious toxicity. To maximize benefit and minimize risk, clinicians must understand the mechanism of action, appropriate indications, range of toxicity and proper dosing of these medications. Furthermore, once initiating therapy, patients need to be monitored appropriately for evidence of efficacy and toxicity. This review includes the rationale behind recommendations for the management and monitoring of patients using immunomodulators. For the purine antagonists--azathioprine and mercaptopurine--the evidence for utility of thiopurine methyltransferase testing and mercaptopurine metabolite monitoring is addressed. The roles of liver biopsy and screening for methylenetetrahydrofolate reductase mutations in patients taking methotrexate are reviewed. With appropriate monitoring, the calcineurin inhibitors--ciclosporin and tacrolimus--can be used safely and effectively. Immunomodulators are important agents for the treatment of Crohn's disease and ulcerative colitis, and prescribing clinicians should be comfortable recognizing both their value and their limitations.
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Affiliation(s)
- C A Siegel
- Gastrointestinal Unit and MGH Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Grucela AL, Steinhagen RM. Restorative Proctocolectomy and Ileal Pouch–Anal Anastomosis for Ulcerative Colitis after Liver Transplant for Primary Sclerosing Cholangitis: Case Report and Review of Literature. Am Surg 2005. [DOI: 10.1177/000313480507100418] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Primary sclerosing cholangitis (PSC) is present in 5 per cent of patients with ulcerative colitis (UC). Conversely, as many as 90 per cent of patients with PSC have been found to have UC. The accepted treatment for advanced PSC is orthotopic liver transplant, and the treatment of ulcerative colitis with concomitant PSC is restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA). A small number of studies have shown that there is an increased risk of pouchitis in UC patients with PSC after ileal pouch-anal anastomosis. We report a case of a 45-year-old male who underwent a two-stage restorative proctocolectomy with IPAA after previous orthotopic liver transplant for PSC. We have reviewed the available literature concerning restorative proctocolectomy after liver transplantation, giving special attention to postoperative complications and subsequent development of pouchitis. It is important to be aware of the possibility of increased risk for development of pouchitis and to follow these patients closely to prevent complications.
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Affiliation(s)
- Alexis L. Grucela
- Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai School of Medicine, Mount Sinai Medical Center, New York, New York
| | - Randolph M. Steinhagen
- Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai School of Medicine, Mount Sinai Medical Center, New York, New York
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Abstract
There is no medical or surgical treatment that provides a permanent cure for Crohn's disease (CD). However, an evolving understanding of the pathogenesis of CD has provided clinicians with a diversity of medical treatment options for the disease. The goal of therapy is to induce and maintain clinical remission. The efficacy of immune-modifying agents such as azathioprine/6-mercaptopurine and infliximab have supported a paradigm shift in CD treatment in which maintenance agents are introduced earlier in the disease course. At the same time, it is imperative to balance the efficacy, safety, and tolerability of medical therapy. Given the variable and relapsing clinical course of CD, the physician and patient should ideally develop an ongoing relationship that allows for individualization of treatment regimens, monitoring of response and side effects, and modification of the therapeutic strategy in the absence of improvement.
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Affiliation(s)
- Shamina Dhillon
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN 55905, USA.
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