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Tome J, Tariq R, Hassett LC, Khanna S, Pardi DS. Effectiveness and Safety Profile of Budesonide Maintenance in Microscopic Colitis: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2024; 30:1178-1188. [PMID: 37589651 DOI: 10.1093/ibd/izad178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Microscopic colitis (MC) is a common cause of chronic diarrhea. Randomized controlled trials (RCTs) have demonstrated the efficacy of budesonide treatment for MC. However, relapse is frequent after discontinuation of budesonide, and data on maintenance therapy are limited. We performed a systematic review and meta-analysis evaluating these outcomes in clinical trials and real-world settings. METHODS A systematic search was performed on October 31, 2022, of Medline, Embase, Cochrane, and Scopus. Case series, case-control, cohort studies, and RCTs of adults with MC were included. Data were pooled using random effects models to calculate weighted pooled estimates and 95% confidence intervals. Heterogeneity was assessed using the I2 statistic. RESULTS We included 35 studies (11 RCTs, 24 observational studies) with 1657 MC patients treated with budesonide induction and 146 for maintenance. The overall pooled clinical remission rate with budesonide treatment was similar between RCTs and observational studies. The pooled remission rate with budesonide maintenance therapy was 84% (95% CI, 0.60-1.00; I2 = 91%). After budesonide discontinuation, the pooled relapse rate was 53% (95% CI, 0.42-0.63; I2 = 76%). On maintenance therapy, no differences were noted in adverse events (eg, metabolic bone disease, hypertension, hyperglycemia, cataracts/glaucoma) in those on budesonide vs placebo or other noncorticosteroid medications for MC (P = .9). CONCLUSIONS Budesonide is an effective maintenance treatment for MC. There is a high risk of recurrence after budesonide discontinuation, but long-term use at the lowest effective dose appears to be relatively safe and have limited adverse effects.
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Affiliation(s)
- June Tome
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Raseen Tariq
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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2
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Rancz A, Teutsch B, Engh MA, Veres DS, Földvári-Nagy L, Erőss B, Hosszúfalusi N, Juhász MF, Hegyi P, Mihály E. Microscopic colitis is a risk factor for low bone density: a systematic review and meta-analysis. Therap Adv Gastroenterol 2023; 16:17562848231177151. [PMID: 37361452 PMCID: PMC10285593 DOI: 10.1177/17562848231177151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/04/2023] [Indexed: 06/28/2023] Open
Abstract
Background Microscopic colitis (MC) is a chronic inflammatory disease of the large bowel characterized by watery diarrhea, substantially decreasing the patient's quality of life. Scarce data suggest that MC is associated with low bone density (LBD). Objectives We aimed to assess whether MC is a risk factor for LBD and the proportion of patients with MC having LBD. Design A systematic review and meta-analysis of studies reporting bone density measurements in MC patients. Data Sources and Methods We systematically searched five databases from inception to October 16, 2021 (Pubmed, Embase, Cochrane, Scopus, and Web of Science). We used the random-effect model to calculate pooled odds ratios (ORs) and pooled event rates with 95% confidence intervals (CIs). To ascertain the quality of evidence of our outcomes, we followed the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. Results The systematic search yielded a total of 3046 articles. Four articles were eligible for quantitative synthesis. All of them used age- and sex-matched controls to evaluate LBD occurrence among patients with MC. The odds of having LBD were twofold increased (OR = 2.13, CI: 1.42-3.20) in the presence of MC, the odds of osteopenia occurrence were 2.4 (OR = 2.45, CI: 1.11-5.41), and of osteoporosis 1.4 (OR = 1.42, CI: 0.65-3.12). The proportion of LBD was 0.68 (CI: 0.56-0.78), osteopenia was 0.51 (CI: 0.43-0.58), and osteoporosis was 0.11 (CI: 0.07-0.16) among the MC population. Our findings' certainty of the evidence was very low following the GRADEPro guideline. Conclusion Our data demonstrate that MC is associated with a twofold risk for LBD. Based on our findings, we suggest screening patients for bone mineral density upon diagnosis of MC. Further prospective studies with higher patient numbers and longer follow-up periods on this topic are needed. Registration Our protocol was prospectively registered with PROSPERO (CRD42021283392).
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Affiliation(s)
- Anett Rancz
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Internal Medicine and Hematology, Medical School, Semmelweis University, Budapest, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Marie Anne Engh
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Dániel Sándor Veres
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - László Földvári-Nagy
- Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Nóra Hosszúfalusi
- Department of Internal Medicine and Hematology, Semmelweis University, Medical School, Budapest, Hungary
| | - Márk Félix Juhász
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Emese Mihály
- Department of Internal Medicine and Hematology, Semmelweis University, Medical School, Szentkirályi Street 46, Budapest 1088, Hungary
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Budesonide Maintenance in Microscopic Colitis: Clinical Outcomes and Safety Profile From a Population-Based Study. Am J Gastroenterol 2022; 117:1311-1315. [PMID: 35417427 PMCID: PMC9612589 DOI: 10.14309/ajg.0000000000001774] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/05/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Outcomes and safety of budesonide maintenance therapy in microscopic colitis (MC) are not well known. METHODS Adult residents of Olmsted County, Minnesota, diagnosed with MC (2002-2019) and treated with budesonide were identified using the Rochester Epidemiology Project. Response was assessed at 12 ± 4 weeks after initiation of therapy and defined as complete (resolution of diarrhea), partial (≥50% improvement in the number of bowel movements), nonresponse (<50% improvement), and intolerance (discontinued because of side effects). For safety outcomes, cases (budesonide maintenance) and MC controls (no budesonide therapy) were matched by sex and age at diagnosis (±2 years). RESULTS A total of 450 patients were identified, of whom 162 (36.0%) were treated with budesonide for induction of clinical remission (median age 67 [23-91] years and 126 women [77.8%] ). Clinical outcomes for induction were as follows: 130 (80.2%) complete response, 22 (13.6%) partial response, 8 (4.9%) no response, and 2 (1.2%) intolerance. After induction, 96 (63.2%) had recurrence after discontinuation, of whom 27 (28.1%) required further budesonide induction treatment without maintenance, 56 (58.3%) required long-term budesonide maintenance, and 13 (13.5%) were treated with other therapies. Of those receiving budesonide maintenance, all responded (55 [98.2%] complete and 1 [1.8%] partial). No patient stopped maintenance from adverse events. The median duration of follow-up was 5.6 years (0.3-18.9). There was no significant difference between cases and controls in the incidence of osteopenia/osteoporosis, diabetes mellitus, hypertension, glaucoma, or cataracts. DISCUSSION The long-term use of budesonide in MC seems to be effective and generally well tolerated with limited adverse effects.
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Khushal S, Oliva-Hemker M. Diagnosis and Management of Microscopic Colitis in Pediatric Patients. Paediatr Drugs 2022; 24:217-233. [PMID: 35501559 DOI: 10.1007/s40272-022-00504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
Microscopic colitis (MC) is an inflammatory disease of the colon, characterized by chronic watery diarrhea with distinguishing histologic findings despite normal endoscopic appearance of the colonic mucosa. MC is a common cause of diarrhea in older adults, though it has been infrequently reported in children and adolescents. As MC is rare in the pediatric population, and the clinical presentation is non-specific, increased awareness of this disease amongst pediatric clinicians and pathologists is essential for timely diagnosis, which requires performing colonoscopy with biopsy. The etiology of MC is incompletely understood, but current theories in pathogenesis inform management strategies. The goals of management in pediatric MC should be to achieve symptomatic improvement while minimizing adverse effects of treatment. Many patients who achieve clinical response have symptomatic recurrence after discontinuation of initial therapy, and may require maintenance medication therapy to sustain remission. This review aims to summarize the epidemiology and risk factors, clinical features, diagnosis, theories regarding pathogenesis, and suggested management approaches for MC in the pediatric population.
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Affiliation(s)
- Salina Khushal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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5
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Graziano EJ, Vaughn BP, Wang Q, Chow LS, Campbell JP. Microscopic Colitis Is Not an Independent Risk Factor for Low Bone Density. Dig Dis Sci 2021; 66:3542-3547. [PMID: 33063187 DOI: 10.1007/s10620-020-06651-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/01/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Microscopic colitis (MC) is a subtype of inflammatory bowel disease (IBD) with overlapping risk factors for low bone density (LBD). While LBD is a known complication of IBD, its association with MC is not well-established. AIMS Assess the prevalence of LBD in MC compared to control populations, and evaluate if MC predicts LBD when controlling for confounders. METHODS Retrospective, observational case control study of adult patients with pathologically confirmed MC from 2005 to 2015. Bone density measurements were abstracted from dual-energy X-ray absorptiometry (DEXA) reports, and bone density was classified using T-score: normal (T ≥ - 1.0), osteopenia (- 1.0 > T > -2.5) or osteoporosis (T ≤ - 2.5). Demographics, disease, medication history and LBD risk factors were obtained from chart review. Prevalence of LBD was compared to national and local controls. A matched control cohort to MC patients without prior diagnosis of LBD was analyzed with logistic regression to assess the relationship of MC to LBD. RESULTS One hundred and eighteen patients with MC were identified. Osteopenia in women with MC was more prevalent compared to national controls (67% vs. 49%, p = 0.0004), and LBD was more prevalent in MC patients compared to local controls (82% vs. 55%, p < 0.0001). In MC patients without prior diagnosis of LBD matched to controls, there was a higher prevalence of osteopenia (53.2% vs. 36.7%, p = 0.04). However, after controlling for confounders, MC was not associated with LBD (OR 0.83, 95% CI 0.22, 3.16, p = 0.8). CONCLUSIONS While LBD was more prevalent in MC patients compared to control populations, with adjustment for key confounders (including BMI, steroids, smoking, vitamin D and calcium use), MC was not an independent predictor of LBD.
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Affiliation(s)
- Elliot J Graziano
- Department of Internal Medicine, University of Minnesota, 420 Delaware Street SE MMC 284, Minneapolis, MN, 55455, USA.
| | - Byron P Vaughn
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Lisa S Chow
- Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, MN, USA
| | - James P Campbell
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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6
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Münch A, Mihaly E, Nagy F, Madisch A, Kupčinskas J, Miehlke S, Bohr J, Bouma G, Guardiola J, Belloc B, Shi C, Aust D, Mohrbacher R, Greinwald R, Munck LK. Budesonide as induction therapy for incomplete microscopic colitis: A randomised, placebo-controlled multicentre trial. United European Gastroenterol J 2021; 9:837-847. [PMID: 34414678 PMCID: PMC8435258 DOI: 10.1002/ueg2.12131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Incomplete microscopic colitis (MCi) is a subtype of microscopic colitis (MC). Budesonide is recommended as a first-line treatment for MC. However, randomised trials on efficacy of treatment in MCi are missing. We therefore performed a randomised, placebo-controlled trial to evaluate budesonide as induction therapy for MCi. METHODS Patients with active MCi were randomly assigned to either budesonide 9 mg once daily or placebo for 8 weeks in a double-blind, double-dummy design. The primary endpoint was clinical remission, defined as a mean of <3 stools/day and a mean of <1 watery stool/day in the 7 days before week 8. RESULTS Due to insufficient patient recruitment, the trial was discontinued prematurely. The intention-to-treat analysis included 44 patients (21 budesonide and 23 placebo). The primary endpoint of clinical remission at week 8 was obtained by 71.4% on budesonide and 43.5% on placebo (p = 0.0582). All clinical secondary endpoints were in favour of budesonide. Budesonide decreased the number of soft or watery stools (16.3 vs. 7.7, p = 0.0186) and improved health-related quality of life for all four dimensions of the short health scale. Adverse events with a suspected relation to study drug were reported in one patient in the budesonide group and two patients in the placebo group. Neither serious nor severe adverse events occurred during the double-blind phase. CONCLUSIONS Budesonide decreased the frequency of soft or watery stools and improved the patients' quality of life significantly in MCi, but the primary endpoint was not met due to the low sample size (type 2 error). Budesonide was safe and well tolerated during the 8-weeks treatment course.
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Affiliation(s)
- Andreas Münch
- Department of Gastroenterology and HepatologyLinköping University Hospital School of MedicineLinköpingSweden
| | - Emese Mihaly
- Department of Internal MedicineSemmelweis EgyetemBudapestHungary
| | - Ferenc Nagy
- First Department of MedicineSzegedi Egyetem ÁOK I sz.SzegedHungary
| | - Ahmed Madisch
- Medical Department IKRH Klinikum SiloahHannoverGermany
| | - Juozas Kupčinskas
- Department of GastroenterologyInstitute for Digestive ResearchLithuanian University of Health SciencesKaunasLithuania
| | - Stephan Miehlke
- Center for Digestive DiseasesInternal Medicine Center EppendorfHamburgGermany
- Centre for Interdisciplinary EndoscopyUniversity Hospital EppendorfHamburgGermany
| | - Johan Bohr
- Division of GastroenterologyDepartment of MedicineÖrebro University HospitalÖrebroSweden
| | - Gerd Bouma
- Department of GastroenterologyVrije Universiteit Medical CentreAmsterdamNetherlands
| | - Jordi Guardiola
- Department of Digestive DiseasesHospital Universitario de BellvitgeBarcelonaSpain
| | - Blanca Belloc
- Department of GastroenterologyHospital San Jorge – University of ZaragozaHuescaSpain
| | - Chunliang Shi
- Department of GastroenterologyNorrlands UniversitetssjukhusUmeåSweden
| | - Daniela Aust
- Institute for PathologyUniversity Hospital Carl Gustav CarusDresdenGermany
| | - Ralf Mohrbacher
- Clinical Research and Development DepartmentDr Falk Pharma GmbHFreiburgGermany
| | - Roland Greinwald
- Clinical Research and Development DepartmentDr Falk Pharma GmbHFreiburgGermany
| | - Lars Kristian Munck
- Department of GastroenterologyZealand University HospitalKøgeDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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Abstract
Microscopic colitis (MC) is an inflammatory disease of the large intestine associated with urgent watery diarrhoea. MC may occur in people of all ages, although the disease primarily affects older women. Once believed to be rare, MC is now known to be a common cause of chronic watery diarrhoea in high-income countries, affecting 1 in 115 women and 1 in 286 men during their lifetime in Swedish population-based estimates. An inappropriate immune response to disturbances in the gut microenvironment is implicated in the pathogenesis of MC. Evidence also supports an underlying genetic basis for disease. The diagnosis of MC relies on clinical symptoms and microscopic assessment of colonic biopsy samples. MC is categorized histologically into collagenous colitis, lymphocytic colitis and their incomplete forms. The mainstay of treatment includes the use of budesonide, with or without adjunctive therapies, and withdrawal of offending drugs. Emerging studies suggest a role for biologicals and immunosuppressive therapies for the management of budesonide-refractory or budesonide-dependent disease. MC can have a substantial negative effect on patient quality of life. The outlook for MC includes a better understanding of the immune response, genetics and the microbiome in disease pathogenesis along with progress in disease management through robust clinical trials.
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Affiliation(s)
- Kristin E Burke
- Gastroenterology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA.
| | - Mauro D'Amato
- Gastrointestinal Genetics Lab, CIC bioGUNE, Basque Research and Technology Alliance (BRTA), Derio, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Siew C Ng
- Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, LK Institute of Health Science, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Hamed Khalili
- Gastroenterology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA.
- Institute of Environmental Medicine, Nutrition Epidemiology, Karolinska Institutet, Solna, Sweden.
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8
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Miehlke S, Guagnozzi D, Zabana Y, Tontini GE, Kanstrup Fiehn A, Wildt S, Bohr J, Bonderup O, Bouma G, D'Amato M, Heiberg Engel PJ, Fernandez‐Banares F, Macaigne G, Hjortswang H, Hultgren‐Hörnquist E, Koulaouzidis A, Kupcinskas J, Landolfi S, Latella G, Lucendo A, Lyutakov I, Madisch A, Magro F, Marlicz W, Mihaly E, Munck LK, Ostvik A, Patai ÁV, Penchev P, Skonieczna‐Żydecka K, Verhaegh B, Münch A. European guidelines on microscopic colitis: United European Gastroenterology and European Microscopic Colitis Group statements and recommendations. United European Gastroenterol J 2021; 9:13-37. [PMID: 33619914 PMCID: PMC8259259 DOI: 10.1177/2050640620951905] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Microscopic colitis is a chronic inflammatory bowel disease characterised by normal or almost normal endoscopic appearance of the colon, chronic watery, nonbloody diarrhoea and distinct histological abnormalities, which identify three histological subtypes, the collagenous colitis, the lymphocytic colitis and the incomplete microscopic colitis. With ongoing uncertainties and new developments in the clinical management of microscopic colitis, there is a need for evidence-based guidelines to improve the medical care of patients suffering from this disorder. METHODS Guidelines were developed by members from the European Microscopic Colitis Group and United European Gastroenterology in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists, pathologists and basic scientists, and voted upon using the Delphi method. RESULTS These guidelines provide information on epidemiology and risk factors of microscopic colitis, as well as evidence-based statements and recommendations on diagnostic criteria and treatment options, including oral budesonide, bile acid binders, immunomodulators and biologics. Recommendations on the clinical management of microscopic colitis are provided based on evidence, expert opinion and best clinical practice. CONCLUSION These guidelines may support clinicians worldwide to improve the clinical management of patients with microscopic colitis.
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Solberg F, Ohlsson B. Microscopic colitis and its associations with complications observed in classic inflammatory bowel disease: a systematic review. Scand J Gastroenterol 2020; 55:312-320. [PMID: 32182146 DOI: 10.1080/00365521.2020.1739325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objectives: Crohn's disease and ulcerative colitis are associated with an increased risk to develop anemia, cutaneous diseases, liver diseases, malignancy, osteoporosis, rheumatic diseases, thromboembolism and uveitis. The association between these diseases and microscopic colitis (MC) is not known. The aim of the present systematic review was to examine associations between MC and diseases observed in association with Crohn's disease and ulcerative colitis.Material and methods: According to the review protocol, original articles which described the prevalence of abovementioned diseases in relation to MC, were searched for in PubMed, Embase and Web of Science.Results: After exclusion of duplicates, 928 articles remained. Based on relevancy of their title, abstract or type of article, 16 articles were ordered in full text and after assessment, nine articles could be included in the review. A second research strategy with individual diseases rendered further two articles. Seven articles covered malignancy/neoplasia, where four showed no association with malignancy and three a reduced association compared with controls. Four articles covering rheumatic diseases showed an association between these diseases and MC. One study showed an association between MC and osteoporosis, whereas one did not. One study showed an association between MC and cutaneous diseases, whereas anemia, eye diseases and thromboembolism showed no associations.Conclusions: Due to short follow-up time in small studies, with selection bias due to exclusion of former or prevalent malignancy in an older population, no conclusions can be drawn concerning the true association between MC and malignancy. Rheumatic diseases seem to be associated with MC.
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Affiliation(s)
- Felix Solberg
- Department of Internal Medicine, Lund University, Skane University Hospital, Malmo, Sweden
| | - Bodil Ohlsson
- Department of Internal Medicine, Lund University, Skane University Hospital, Malmo, Sweden
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10
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Reilev M, Hallas J, Thomsen Ernst M, Nielsen GL, Bonderup OK. Long-term oral budesonide treatment and risk of osteoporotic fractures in patients with microscopic colitis. Aliment Pharmacol Ther 2020; 51:644-651. [PMID: 32003028 DOI: 10.1111/apt.15648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/05/2019] [Accepted: 01/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Due to a substantial first-pass metabolism of oral budesonide, systemic bioavailability is low compared to other oral corticosteroids, thereby possibly avoiding adverse effects of systemic corticosteroid use. AIM To determine whether use of oral budesonide is associated with osteoporotic fractures in patients with microscopic colitis (MC). METHODS Applying data from the Danish nationwide health registries, we conducted a case-control study nested within a cohort of patients with MC from 2004 to 2012. We estimated odds ratios (ORs) for the association between budesonide use and osteoporotic fractures (hip, wrist and spinal fractures). RESULTS We identified 417 cases with a first occurrence of an osteoporotic fracture. Eighty-six per cent were women and the median age was 78 years. The OR for the overall association between ever-use of budesonide and any osteoporotic fractures did not reach statistical significance (OR 1.13, CI: 0.88-1.47). The highest risk was observed for spinal fractures (OR 1.98, CI: 0.94-4.17), where a dose-response association seemed to exist, followed by hip and wrist fractures (OR 1.17 [CI: 0.79-1.73] and OR 0.99 [CI: 0.66-1.47] respectively). We generally found modestly increased ORs across subgroups at suspected high or low risk of fractures (1.00-2.49). No overall dose-response association was evident (OR for doubling of cumulative dose 0.93 (CI: 0.84-1.03). CONCLUSION No overall association between use of oral budesonide and osteoporotic fractures was demonstrated among individuals with MC. There seemed to be an isolated adverse effect of budesonide on the risk of spinal fractures, which appears to be dose related.
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Affiliation(s)
- Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Martin Thomsen Ernst
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense University Hospital, Odense, Denmark.,OPEN - Open Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Gunnar Lauge Nielsen
- Department of Internal Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ole K Bonderup
- Diagnostic Centre, Regional Hospital Silkeborg, and University Research Clinic for Innovative Patient Pathways, Aarhus University, Aarhus, Denmark
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11
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Townsend T, Campbell F, O’Toole P, Probert C. Microscopic colitis: diagnosis and management. Frontline Gastroenterol 2019; 10:388-393. [PMID: 31656564 PMCID: PMC6788131 DOI: 10.1136/flgastro-2018-101040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/15/2018] [Accepted: 11/18/2018] [Indexed: 02/04/2023] Open
Abstract
Microscopic colitis (MC) is a common cause of chronic, non-bloody, watery diarrhoea in older patients. The diagnosis depends on characteristic histological findings. Bile acid malabsorption and autoimmune conditions, including coeliac disease, are more frequently found in patients with MC, but colorectal neoplasia and mortality are not increased. Non-steroidal anti-inflammatory drugs, proton-pump inhibitors, selective serotonin reuptake inhibitors and smoking tobacco confer an increased risk of developing MC. Although a so-called benign disease, which rarely causes serious complications, it does have an impact on the quality of life. Several treatment options exist, but budesonide is the only treatment proven in randomised-controlled trials to be effective and safe for induction and maintenance of remission. This article provides a practical overview for the gastroenterologist looking after patients with MC.
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Affiliation(s)
- Tristan Townsend
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Fiona Campbell
- Department of Pathology, Royal Liverpool University Hospital, Liverpool, UK
| | - Paul O’Toole
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Chris Probert
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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12
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Abstract
Microscopic colitis (MC), encompassing lymphocytic and collagenous colitis, is a common cause for chronic nonbloody diarrhoea, which impacts significantly on the quality of life for patients. Despite increasing awareness of the condition and its treatment, there is considerable variation in therapeutic approaches. To conduct a systematic review and meta-analysis on the efficacy and safety of budesonide in the treatment of MC. We searched Medline, Embase and Central databases using predefined search methodology for randomised trials using budesonide in the treatment of MC. We extracted data, on the efficacy and safety of budesonide, from studies identified that met the feasibility for analysis criteria. These data were pooled with a fixed effects model. Nine studies met the inclusion criteria for analysis. The pooled odds ratios (ORs) for a response to budesonide therapy at induction and maintenance were 7.34 [95% confidence interval (CI): 4.08-13.19] and 8.35 (95% CI: 4.14-16.85) respectively. Histological response rates were superior in budesonide-treated patients compared to placebo following induction (OR: 11.52; 95% CI: 5.67-23.40) and maintenance treatment (OR: 5.88; 95% CI: 1.90-18.17). There was no difference in adverse events. Significant relapse rates (>50%) were observed following treatment cessation with no difference noted between the budesonide or the placebo-treated patients. Budesonide is an effective treatment option for MC for achieving induction and maintenance of both clinical and histological response. High relapse rates on treatment cessation were observed.
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