Experiences with 6-mercaptopurine and azathioprine therapy in pediatric patients with severe ulcerative colitis

Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND

The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points.

METHODS

These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate.

RESULTS

These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines.

CONCLUSIONS

These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.

Monitoring thiopurine metabolites in korean pediatric patients with inflammatory bowel disease

PURPOSE

This study aimed to assess the role of thiopurine S-methyltransferase (TPMT) and 6-thioguanine nucleotide (6-TGN) as predictors of clinical response and side effects to azathioprine (AZA), and estimate the optimal AZA dose in Korean pediatric inflammatory bowel disease (IBD) patients.

MATERIALS AND METHODS

One hundred and nine pediatric IBD patients in whom AZA treatment was required were enrolled. Thiopurine metabolites were monitored since September 2010. Among them, 83 patients who had prescribed AZA for at least 3 months prior to September 2010 were enrolled and followed until October 2011 to evaluate optimal AZA dose, adverse effects and disease activity before and after thiopurine metabolite monitoring.

RESULTS

The result of the TPMT genotype was that 102 patients were *1/*1 (wild type), four were *1/*3C, one was *1/*6, one was *1/*16 (heterozygote) and one was *3C/*3C (homozygote). Adverse effects happened in 31 patients pre-metabolite monitoring and in only nine patients post-metabolite monitoring. AZA dose was 1.4±0.31 mg/kg/day before monitoring and 1.1±0.46 mg/kg/day after monitoring (p<0.001). However, there were no statistical differences in disease activity during metabolite monitoring period (p=0.34). Adverse effects noticeably decreased although reduction of the AZA dose since monitoring.

CONCLUSION

TPMT genotype and thiopurine metabolite monitoring could be helpful to examine TPMT genotypes before administering AZA and to measure 6-TGN concentrations during prescribing AZA in IBD patients.

Clinical course of infliximab treatment in korean pediatric ulcerative colitis patients: a single center experience

PURPOSE

Infliximab (IFX) is considered safe and effective for the treatment of ulcerative colitis (UC) in both adults and children. The aim of this study was to evaluate the short- and long-term clinical course of IFX in Korean children with UC.

METHODS

Pediatric patients with UC who had received IFX infusions between November 2007 and May 2013 at Samsung Medical Center were retrospectively investigated. The clinical efficacy of IFX treatment was evaluated at 8 weeks (short term) and 54 weeks (long term) after the initiation of IFX treatment using the Pediatric Ulcerative Colitis Activity Index (PUCAI). The degree of response to IFX treatment was defined as complete response (PUCAI score=0), partial response (decrement of PUCAI score≥20 points), and non-response (decrement of PUCAI score <20 points). Adverse events associated with IFX treatment were also investigated.

RESULTS

Eleven pediatric patients with moderate to severe UC had received IFX. The remission rate after IFX treatment was 46% (5/11) and 82% (9/11) at 8 weeks and 54 weeks after IFX treatment, respectively. All patients who were steroid-dependent before treatment with IFX achieved remission at 54 weeks and were able to stop treatment with corticosteroids, while all steroid-refractory patients failed to achieve remission at 54 weeks after treatment with IFX.

CONCLUSION

Response to IFX treatment after 8 weeks may predict a favorable long-term response to IFX treatment in Korean pediatric UC patients.

The long-term efficacy of azathioprine in steroid-dependent ulcerative colitis

OBJECTIVE. The long-term efficacy of azathioprine (AZA) in steroid-dependent ulcerative colitis (UC) is still unclear. We aimed to evaluate the efficacy of AZA in patients with steroid-dependent UC. MATERIAL AND METHODS. We retrospectively reviewed the medical records of 106 patients with steroid-dependent UC who were administered AZA. Three-year outcomes of AZA therapy were evaluated. The outcome of the treatment was defined as (1) success, indicating induction and maintenance of remission throughout the study period (complete success) or remission followed by infrequent and short relapses (partial success); or (2) failure, indicating the absence of remission, frequent or prolonged relapses, infliximab administration, or colectomy. RESULTS. Of the 106 patients, 73 (68.9%) continued on AZA for >6 months (AZA therapy group) and 33 (31.1%) discontinued AZA within 6 months due to intolerance (AZA intolerance group, n = 20), colectomy (n = 6), or follow-up loss (n = 7). Three-year outcomes for 106 patients were success in 54.7% (complete success, 35.8%; partial success, 18.9%), failure in 32.1% (frequent or prolonged relapses, 12.3%; infliximab administration, 5.6%; colectomy, 14.2%), and follow-up loss or death in 13.2%. The success rate increased to 71.2% (complete success, 46.6%; partial success, 24.7%) when the analysis was confined to the 73 patients who continued AZA for > 6 months. The 3-year success rate was higher in the AZA therapy group (71.2%) than the AZA intolerance group (25.0%) (p < 0.001). CONCLUSIONS. AZA is an effective treatment for steroid-dependent UC. The efficacy of AZA is well sustained over 3 years.

Varicella zoster virus infection in inflammatory bowel disease

BACKGROUND

The risk of viral infection is increased in immunosuppressed inflammatory bowel disease (IBD) patients. Varicella zoster virus (VZV) is of particular interest in IBD because of a number of reports of severe, disseminated, and occasionally fatal varicella infection in immunosuppressed IBD patients.

METHODS

We reviewed publications describing VZV infection in IBD patients and combined these data with a review of the current literature relating to both primary and secondary varicella in IBD.

RESULTS

Twenty cases of primary varicella infection and 32 cases of herpes zoster infection have been reported in IBD. Additional cases are reported in clinical trials. The risk of VZV infection is increased with all immunosuppressants used in IBD, but corticosteroids and combination immunosuppression appear to be a particular risk.

CONCLUSIONS

Healthcare providers need to be aware of the various manifestations of primary and secondary VZV infection in immunosuppressed IBD patients. Patients should be screened for VZV immunity and vaccinated prior to commencing immunosuppression.

Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines

BACKGROUND AND AIMS

Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

METHODS

A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature.

RESULTS

A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented.

CONCLUSIONS

These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

Intermittent granulocyte and monocyte apheresis versus mercaptopurine for maintaining remission of ulcerative colitis: a pilot study

The effect of granulocyte and monocyte adsorption apheresis (GMA) on prevention of relapse of ulcerative colitis (UC) is not clear. This was a pilot open-labeled, prospective, randomized, unblinded study to compare the tolerability and efficacy of intermittent GMA (once every 2 weeks) with mercaptopurine to maintain remission of UC. Twenty-one patients with UC, who had achieved remission by induction therapies were randomly assigned to receive either intermittent GMA (N = 10) or oral mercaptopurine (0.5 mg/kg per day; N = 11). The study period was 24 months. The rate of the patients maintaining remission and the incidences of adverse effects were compared between the two groups. At 24 months, seven of 10 patients (70.0%) on intermittent GMA and seven of 11 patients (63.6%, P = 1.00) on oral mercaptopurine were still in remission. Three patients relapsed in each group. One patient taking mercaptopurine, but none receiving intermittent GMA, dropped out because of adverse effects. Intermittent therapy with GMA was well tolerated and a substantial proportion of patients maintained remission. Intermittent GMA therapy in maintaining remission of UC merits further investigation.

Do children with IBD really respond better than adults to thiopurines?

BACKGROUND AND OBJECTIVES

Children and adolescents with inflammatory bowel disease (IBD) have more extensive and severe disease than adults. Despite a lack of comparative studies, thiopurines are frequently cited as being more efficacious in children. To test this assertion, we compared the efficacy of thiopurines in children with IBD with that in adults matched for disease phenotype.

PATIENTS AND METHODS

Fifty paediatric and adult patients with IBD started on a thiopurine were matched for sex, disease type, and extent. Retrospective data were obtained by electronic case note review, and corticosteroid-free clinical remission and tolerance rates at 6 months as well as relapse rates during the subsequent year were recorded.

RESULTS

Adverse effects caused discontinuation of thiopurines in 1 of 50 children and 16% (8/50) of adults (P < 0.05). At 6 months, steroid-free remission was achieved in 30% (15/50) of children and 38% (19/50) of adults (P = 0.53). No differences in remission rates were seen according to disease type. At the end of the following year, 73% (11/15) of children and 68% (13/19) of adults remained in remission (P = 1).

CONCLUSIONS

Thiopurines are tolerated better by children. When phenotype is matched, there is no difference in the therapeutic response to thiopurines between children and adults with IBD.

Clinical characteristics of idiopathic ulcerative colitis in children

INTRODUCTION

Idiopathic ulcerative colitis (IUC) represents a rare disease of childhood. It usually occurs at age over 10 years, and below that exceptionally rarely.

OBJECTIVE

The aim of the paper was to analyze the clinical signs, symptoms and therapeutic procedures in children with IUC.

METHODS

The aims of the paper were based on a sample of 17 children (11 male and 6 female, mean age 11.90 +/- 3.50 years; range 3.8-17.5 years) with IUC. The disease diagnosis was based on characteristic endoscopic and pathohistological findings.

RESULTS

The basic signs of the disease involved chronic mucosal haemorrhagic diarrhoea which was confirmed in 16 of 17 patients, with body weight deficiency (10), recurrent abdominal pain (6), fever (5), slowed-down maturation (5), marked anorexia (4), and tenesmus (3).Two patients had recurrent aphthous stomatitis, 2 anal fissures, 2 arthralgia, one autoimmune hepatitis and one pyoderma gangrenosum. None of the children had longitudinal growth retardation. Elevated sedimentation rate and C-reactive protein in blood were registered in 11, sideropenia in 10, anaemia in 6 and hypoalbuminemia in 3 patients. The remission of proctosigmoiditis and left-sided colitis was achieved with aminosalicylates, and of pancolitis with the combination of aminosalicylates and glucocorticoids, except in cases of steroid-dependent colitis, which additionally required azathioprine.

CONCLUSION

The main signs of IUC in children are chronic mucous haemorrhagic diarrhoea, body weight loss and sideropenic anaemia, while the basic therapy consists of aminosalicylates, and in more severe cases of the disease the initial use of glucocorticoids and later azathioprine.

Outcome following thiopurine use in children with ulcerative colitis: a prospective multicenter registry study

OBJECTIVES

Despite little supporting data, thiopurine use is common in pediatric ulcerative colitis (UC). Our aim was to determine outcome following thiopurine use in a multicenter inception cohort of children diagnosed with UC.

METHODS

Data were obtained from a prospective observational study of newly diagnosed children <16 years of age. Data are recorded at diagnosis, 30 days, and quarterly. Patients are managed by physician dictates not protocol. Disease activity is classified by physician global assessment. The primary outcome was corticosteroid (CS)-free inactive UC at 1 year following thiopurine initiation without the need for rescue therapy (infliximab, calcineurin inhibitors, or colectomy).

RESULTS

Of 1,490 patients in our registry, 394 have UC (mean age at diagnosis 11.3±3.7 years); 197 (50%) received thiopurine (49% ≤3 months from diagnosis). Also, 84% were receiving CSs and 60% 5-aminosalicylates at thiopurine start. Of the 197 patients, there was insufficient follow-up (41), previous or concomitant use of infliximab (16), or calcineurin inhibitor (7), leaving 133 patients evaluable at 1 year. Of these, 65 (49%) had CS-free inactive UC without rescue therapy. CS-free inactive disease at 1 year after initiating thiopurine was not affected by starting thiopurine ≤3 months vs. >3 months from diagnosis, gender, age, or concomitant treatment with 5-aminosalicylates. Kaplan-Meier analysis showed that the likelihood of remaining free of rescue therapy in the thiopurine-treated patients was 73% at 1 year.

CONCLUSIONS

Approximately 50% of children with UC starting thiopurine without previous or concomitant biologic or calcineurin inhibitor therapy have CS-free inactive disease 1 year later without the need for rescue therapy.

Consensus for managing acute severe ulcerative colitis in children: a systematic review and joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN

OBJECTIVES

Acute severe ulcerative colitis (ASC) is a potentially life-threatening disease. We aimed to formulate guidelines for managing ASC in children based on systematic review of the literature and robust consensus process. This manuscript is a product of a joint effort of the ECCO (European Crohn's and Colitis Organization), the Pediatric Porto Inflammatory Bowel Disease (IBD) Working group of ESPGHAN (European Society of Pediatric Gastroenterology, Hepatology, and Nutrition) and ESPGHAN.

METHODS

A group of 19 experts in pediatric IBD participated in an iterative consensus process including two face-to-face meetings. A total of 17 predefined questions were addressed by working subgroups based on a systematic review of the literature.

RESULTS

The recommendations and practice points were eventually endorsed with a consensus rate of at least 95% regarding: definitions, initial evaluation, standard therapy, timing of second-line therapy, the role of endoscopic evaluation and heparin prophylaxis, how to administer second-line medical therapy, how to assess response, surgical considerations, and discharge recommendations. A management flowchart is presented based on daily scoring of the Pediatric Ulcerative Colitis Activity Index (PUCAI), along with 28 formal recommendations and 34 practice points.

CONCLUSIONS

These guidelines provide clinically useful points to guide the management of ASC in children. Taken together, the recommendations offer a standardized protocol that allows effective monitoring of disease progress and timely treatment escalation when needed.

Drug-induced acute pancreatitis related to medications commonly used in gastroenterology

BACKGROUND

With the growing number of pharmacological agents available nowadays, the gastrointestinal drug-induced side effects become more common than ever. However, drug-induced pancreatitis belongs to rather seldom reported adverse drug reactions, probably because of the difficulty in proving the relationship between an inflammation of the pancreas and the pharmacotherapy with a certain drug.

AIM

The aim of this review is to draw attention to an infrequent but real problem of drug-induced acute pancreatitis associated with medications commonly used in the treatment of gastrointestinal disorders.

METHODOLOGY

For the purpose of that the PubMed database was searched using the keywords "drug-induced pancreatitis", "drug-associated pancreatitis", "acute pancreatitis", "pancreatitis" in various combinations and relevant literature was reviewed.

RESULTS

A substantial number of drugs commonly prescribed for gastrointestinal disorders are known to cause acute pancreatitis. Case reports and review articles published so far draw attention to medications already known to cause drug-induced pancreatic damage as well as implicate new drugs. Generally, the etiopathological mechanisms involved in drug-induced pancreatitis remain unclear. It is difficult to establish or rule out definitely such unwanted event, especially in patients taking numerous medications prescribed for multiple comorbidities.

CONCLUSION

Pharmacological agents are among etiologic factors that should be considered in all patients presenting with signs and symptoms consistent with acute pancreatitis. The diagnosis of drug-induced AP is often difficult to established. Therefore a high index of suspicion and thorough drug history are crucial for making the final diagnosis.

Monitoring 6-thioguanine nucleotide concentrations in Japanese children and adolescents with inflammatory bowel disease

BACKGROUND AND AIM

6-Mercaptopurine (6-MP) and azathioprine (AZA) are widely used as maintenance therapy in children with inflammatory bowel disease (IBD). However, proper 6-thioguanine nucleotide (6-TGN) concentrations in Japanese children with IBD have not been reported.

METHODS

This retrospective review examines 32 ulcerative colitis (UC) patients and 19 Crohn's disease (CD) patients (12.87 ± 3.56 years) who required 6-MP or AZA to maintain disease remission. All patients were treated with 6-MP or AZA for at least 3 weeks prior to this study in addition to previous treatment. 6-MP dose, 6-TGN levels, assayed by high-performance liquid chromatography, as well as laboratory data were evaluated.

RESULTS

Thirty-five children were successfully kept in remission with 6-MP and AZA therapy after weaning off corticosteroids. Overall, 123 measurements (59 active disease, 64 in remission) were analyzed. The mean 6-TGN concentration of the entire study population was 499.61 ± 249.35 pmol/8 × 10(8) red blood cell. The mean 6-MP dose in patients with active disease (0.910 ± 0.326 mg/kg per day) was significantly higher than for patients in remission (0.749 ± 0.225) (P = 0.0016). A significant inverse correlation was found between white blood cell counts and 6-TGN concentrations (r = 0.275, P < 0.002). Two patients experienced leukopenia with alopecia, and four transiently experienced increased serum levels of pancreatic enzymes, although no thiopurine S-methyl transferase mutations were confirmed.

CONCLUSION

The doses of 6-MP or AZA needed to maintain remission in Japanese children with IBD are lower than those reported in Western countries. However, 6-TGN concentrations in this population are higher than previously reported.

Systematic review of the evidence base for the medical treatment of paediatric inflammatory bowel disease

OBJECTIVE

To systematically review the evidence base for the medical (pharmaceutical and nutritional) treatment of paediatric inflammatory bowel disease.

METHODS

Key clinical questions were formulated regarding different treatment modalities used in the treatment of paediatric (not adult-onset) IBD, in particular the induction and maintenance of remission in Crohn disease and ulcerative colitis. Electronic searches were performed from January 1966 to December 2006, using the electronic search strategy of the Cochrane IBD group. Details of papers were entered on a dedicated database, reviewed in abstract form, and disseminated in full for appraisal. Clinical guidelines were appraised using the AGREE instrument and all other relevant papers were appraised using Scottish Intercollegiate Guidelines Network methodology, with evidence levels given to all papers.

RESULTS

A total of 6285 papers were identified, of which 1255 involved children; these were entered on the database. After critical appraisal, only 103 publications met our criteria as evidence on medical treatment of paediatric IBD. We identified 3 clinical guidelines, 1 systematic review, and 16 randomised controlled trials; all were of variable quality, with none getting the highest methodological scores.

CONCLUSIONS

This is the first comprehensive review of the evidence base for the treatment of paediatric IBD, highlighting the paucity of trials of high methodological quality. As a result, the development of clinical guidelines for managing children and young people with IBD must be consensus based, informed by the best-available evidence from the paediatric literature and high-quality data from the adult IBD literature, together with the clinical expertise and multidisciplinary experience of paediatric IBD experts.

Pediatric inflammatory bowel disease: highlighting pediatric differences in IBD

Inflammatory bowel disease (IBD) includes Crohn disease and ulcerative colitis, and is often diagnosed in late childhood and early adulthood. What determines the age of onset remains unexplained. Early onset may represent the "pure" form of the disease process and hence may hold secrets of the initiating events of IBD pathogenesis. Clinical scientists continue to focus on pediatric IBD because it may shed light on the cause and prevention of this lifelong disease. Over the last decade, data in pediatric IBD studies have demonstrated many similarities and differences between pediatric and adult onset, which continue to add pieces to an increasingly complex IBD puzzle. The mechanism responsible for these similarities and differences remains unanswered. This article discusses clinically relevant epidemiology and treatment aspects of pediatric IBD, with special focus on similarities and differences in pediatric and adult IBD. Evidence-based treatment algorithms, with special focus on pediatric studies and care for children, are also highlighted.

Pediatric inflammatory bowel disease: highlighting pediatric differences in IBD

Inflammatory bowel disease (IBD) includes Crohn disease and ulcerative colitis, and is often diagnosed in late childhood and early adulthood. What determines the age of onset remains unexplained. Early onset may represent the "pure" form of the disease process and hence may hold secrets of the initiating events of IBD pathogenesis. Clinical scientists continue to focus on pediatric IBD because it may shed light on the cause and prevention of this lifelong disease. Over the last decade, data in pediatric IBD studies have demonstrated many similarities and differences between pediatric and adult onset, which continue to add pieces to an increasingly complex IBD puzzle. The mechanism responsible for these similarities and differences remains unanswered. This article discusses clinically relevant epidemiology and treatment aspects of pediatric IBD, with special focus on similarities and differences in pediatric and adult IBD. Evidence-based treatment algorithms, with special focus on pediatric studies and care for children, are also highlighted.

The natural history of pediatric ulcerative colitis: a population-based cohort study

OBJECTIVES

The natural history of ulcerative colitis (UC) has been poorly described in children.

METHODS

In a geographically derived incidence cohort diagnosed from 1988 to 2002, we identified 113 UC patients (age 0-17 years at diagnosis) with a follow-up of at least 2 years. The cumulative risk of colectomy was estimated by the Kaplan-Meier method. Risk factors for disease extension were assessed with logistic regression models, and risk factors for colectomy with Cox hazards proportional models.

RESULTS

Median follow-up time was 77 months (46-125). At diagnosis, 28% of patients had proctitis, 35% left-sided colitis, and 37% extensive colitis. Disease course was characterized by disease extension in 49% of patients. A delay in diagnosis of more than 6 months and a family history of inflammatory bowel disease were associated with an increased risk of disease extension, with odds ratios of 5.0 (1.2-21.5) and 11.8 (1.3-111.3), respectively. The cumulative rate of colectomy was 8% at 1 year, 15% at 3 years, and 20% at 5 years. The presence of extra-intestinal manifestations (EIMS) at diagnosis was associated with an increased risk of colectomy (hazard ratio (HR)=3.5 (1.2-10.5)). Among the patients with limited disease at diagnosis, the risk of colectomy was higher in those who experienced disease extension than in those who did not (HR=13.3 1.7-101.7).

CONCLUSIONS

Pediatric UC was characterized by widespread localization at diagnosis and a high rate of disease extension. Twenty percent of children had their colon removed after 5 years. The colectomy rate was influenced by disease extension and was associated with the presence of EIMS at diagnosis.

Meta-analysis: the efficacy of azathioprine and mercaptopurine in ulcerative colitis

BACKGROUND

Debate exists regarding to whether thiopurine therapy is as effective in ulcerative colitis (UC) as it is in Crohn's disease.

AIM

To review systematically the efficacy of azathioprine (AZA) and mercaptopurine (MP) in UC, and to conduct a meta-analysis of randomized clinical trials evaluating the efficacy of AZA/MP for the induction or maintenance of UC clinical remission.

SELECTION OF STUDIES

Evaluating AZA/MP for induction and/or maintenance of clinical remission of UC. Randomized-controlled-trials comparing AZA/MP with placebo/5-aminosalicylates were included in the meta-analysis.

SEARCH STRATEGY

Electronic and manual. Study quality: Independently assessed by two reviewers.

DATA SYNTHESIS

By 'intention-to-treat'.

RESULTS

Thirty noncontrolled studies (1632 patients) were included in the systematic review. Mean efficacy of AZA/MP was 65% for induction and 76% for maintenance of the remission. Seven controlled studies were included in the meta-analysis. (i) Induction of remission: four studies (89 AZA/MP-treated patients) showed mean efficacy of 73% vs. 64% in controls (OR = 1.59; 95% CI = 0.59-4.29). (ii) Maintenance of remission: six studies (124 AZA/MP-treated patients) showed mean efficacy of 60% vs. 37% in controls (OR = 2.56; 95% CI = 1.51-4.34). When only studies comparing AZA/MP vs. placebo were considered, OR was 2.59 (95% CI = 1.26-5.3), absolute risk reduction was 23% and number-needed-to-treat (NNT) to prevent one recurrence was 5.

CONCLUSION

Thiopurine drugs (AZA/MP) are more effective than placebo for the prevention of relapse in UC, with an NNT of 5 and an absolute risk reduction of 23%.

Comparative effectiveness of azathioprine in Crohn's disease and ulcerative colitis: prospective, long-term, follow-up study of 394 patients

BACKGROUND

The long-term efficiacy for thiopurinic drugs in Crohn's disease (CD), and particularly in ulcerative colitis (UC), has been insufficiently studied.

AIM

To evaluate prospectively and compare the long-term effectiveness of azathioprine (AZA) in CD and UC.

METHODS

Three hundred and ninety-four AZA treated patients were included consecutively included. Truelove-modified index and CDAI were used to assess effectiveness. Hospitalizations and surgical procedures were recorded.

RESULTS

Two hundred and thirty-eight patients with CD and 156 with UC received AZA for a median of 38 months.

EFFECTIVENESS

Partial response/remission was achieved in 34%/49% of CD patients and in 47%/42% of UC (nonstatistically significant differences). STEROID TREATMENT: Prior to AZA, 49% of CD patients were receiving steroids, whereas only 8% needed steroids after therapy (P < 0.001). Corresponding figures in UC patients were 39% vs. 9% (P < 0.001). HOSPITALIZATIONS: Prior to AZA, the rate of hospitalizations in CD was 0.190 per-patient-year, while after treatment, it decreased to 0.099 (P < 0.001). Corresponding hospitalization rates in UC were 0.108 vs. 0.038 (P < 0.001).

SURGERY

The rate of surgery in CD prior/after AZA was 0.038/0.011 per-patient-year (P < 0.001). The number of surgical interventions in UC prior/after AZA treatment was 26/0 (the rate per-patient-year was 0.018/0) (P < 0.001).

CONCLUSIONS

Our results confirm the effectiveness of AZA in inflammatory bowel disease, not only in the short term but also in the long term, resulting in a steroid sparing effect and in both a reduction in the number of hospitalizations and surgical procedures. AZA is similarly effective for both CD and UC patients.

Thiopurine-induced myelotoxicity in patients with inflammatory bowel disease: a review

AIM

Probably, the most important and potentially lethal adverse event of azathioprine (AZA) and mercaptopurine (MP) is myelosuppression. Our aim was to conduct a review of AZA/MP-induced myelotoxicity in inflammatory bowel disease (IBD) patients.

METHODS

Bibliographical searches were performed in MEDLINE/EMBASE. The studies evaluating thiopurine-induced myelotoxicity in patients with IBD were reviewed. The cumulative incidence and the incidence rate of AZA/MP-induced myelotoxicity were calculated by a meta-analysis.

RESULTS

In total, 66 studies (8,302 patients) were included. The cumulative incidence of AZA/MP-induced myelotoxicity was 7% (95% confidence interval [CI] 6-8%). The incidence rate (per patient and year of treatment) of the drug-induced myelotoxicity was 3% (95% CI 3-4%). The risk was roughly similar with AZA and with MP (7%vs 9%). The duration of AZA/MP treatment in patients with myelotoxicity ranged from 12 days to 27 yr. The cumulative incidence of infections among AZA/MP-induced myelotoxicity patients was 6.5%. The cumulative incidence of severe myelotoxicity was 1.1% (incidence rate 0.9%). Three deaths were reported due to myelotoxicity (cumulative incidence 0.06%, 95% CI 0.02-0.17%). The risk of death among patients who developed myelotoxicity was 0.94% (95% CI 0.32-2.70%).

CONCLUSION

The incidence rate of myelotoxicity in IBD patients receiving AZA/MP is approximately 3% per patient and year of treatment. Although bone marrow toxicity may develop at any time after starting the therapy, this happens more frequently during the first months. The incidence rate of severe myelotoxicity is less than 1% per patient and year of treatment, and the mortality risk is less than 0.1% (which means that the risk of death among IBD patients who develop myelotoxicity is approximately 1%).

Specific considerations in the treatment of pediatric inflammatory bowel disease

Inflammatory bowel disease is one of the most prevalent chronic inflammatory disorders and commonly presents during childhood or adolescence. Occurring during a critical period of growth and development, pediatric Crohn's disease and ulcerative colitis require special consideration. Children often experience growth failure, malnutrition, pubertal delay and bone demineralization. Medical treatment must be optimized to promote clinical improvement and reverse growth failure with minimal toxicity. In addition to pharmacologic and surgical interventions, nutritional therapies play a vital role in the management of pediatric inflammatory bowel disease. This review will outline the epidemiology and clinical complications that are unique to pediatric inflammatory bowel disease, current trends, and recent advances in nutritional and pharmacologic treatment, and projected future therapeutic direction.

Thiopurine metabolite monitoring in paediatric inflammatory bowel disease

BACKGROUND

Measurement of thiopurine metabolite levels may be useful as a clinical tool to optimize thiopurine treatment of paediatric inflammatory bowel disease (IBD).

AIM

The authors evaluated correlations between 6-thioguanine nucleotide (6-TGN) and therapeutic response, metabolite levels and drug toxicity.

METHODS

Fifty-six paediatric IBD patients treated with thiopurines had 326 metabolite level measurements and were retrospectively reviewed. Clinical status and laboratory parameters were compared with metabolite levels.

RESULTS

There was significant correlation between 6-TGN levels and therapeutic response, with higher median 6-TGN levels among patients with therapeutic response than those with non-therapeutic response (194 vs. 146 pmol/8 x 10(8) RBC; P = 0.0004). Patients with 6-TGN levels >235 pmol/8 x 10(8) RBC were more likely to achieve therapeutic response than those below the cut-off (odds ratio, 2.5; 95% CI, 1.5-4.1). Patients who developed leukopenia tended to have higher median 6-TGN levels than those without leukopenia (261 vs. 160 pmol/8 x 10(8) RBC) but the difference was not statistically significant. There was no correlation between 6-methylmercaptopurine levels and hepatotoxicity. Two patients developed acute pancreatitis. Metabolite level measurements were helpful in identifying non-compliance in nine patients.

CONCLUSIONS

Monitoring of thiopurine metabolite levels is useful to guide and optimize dosing, as an adjunct to clinical judgement, blood count and liver biochemistry measurements to minimize the risk of drug toxicity and to confirm non-compliance.

Current therapy of inflammatory bowel disease in children

Ulcerative colitis (UC) and Crohn disease (CD) are chronic intestinal inflammatory diseases that can present as bloody diarrhea, abdominal pain, and malnutrition. Collectively, these disorders are referred to as inflammatory bowel disease (IBD). All patients with IBD share a common pathophysiology. However, there are a number of developmental, psychosocial, and physiologic issues that are unique to the approximate, equals 20% of patients that present during childhood or adolescence. These include the possibility of disease-induced delays in linear growth or physical development, differences in drug dosing, and the changes in social and cognitive development that occur as children move from school-age years into adolescence and early adulthood. Gastroenterologists caring for these children must therefore develop an optimal regimen of pharmacologic therapies, nutritional management, psychologic support, and properly timed surgery (when necessary) that will maintain disease remission, minimize disease and drug-induced adverse effects, and optimize growth and development. This article reviews current approaches to the management of patients with UC and CD and highlights issues specific to the treatment of children with IBD. The principal medical therapies used to induce disease remission in patients with UC are aminosalicylates (for mild disease), corticosteroids (for moderate disease), and cyclosporine (ciclosporin) (for severe disease). If a patient responds to the induction regimen, maintenance therapies that are used to prevent disease relapse include aminosalicylates, mercaptopurine, and azathioprine. Colectomy with creation of an ileal pouch anal anastomosis (J pouch) has become the standard of care for patients with severe or refractory colitis and results in an improved quality of life in most patients. Therefore, the risks associated with using increasingly potent immunosuppressant agents must be balanced in each case against a patient's desire to retain their colon and avoid a temporary or potentially permanent ileostomy. Decisions about drug therapy in the management of patients with CD are more complex and depend on both the location (e.g. gastroduodenal vs small intestinal vs colonic), as well as the behavior of the disease (inflammatory/mucosal vs stricturing vs perforating) in a given patient. Induction therapies for CD typically include aminosalicylates and antibiotics (for mild mucosal disease), nutritional therapy (including elemental or polymeric formulas), corticosteroids (for moderate disease), and infliximab (for corticosteroid-resistant or fistulizing disease). Aminosalicylates, mercaptopurine, azathioprine, methotrexate, and infliximab can be used as maintenance therapies. Because surgical treatment of CD is not curative, it is typically reserved for those patients either with persistent symptoms and disease limited to a small section of the intestine (e.g. the terminal ileum and cecum) or for the management of complications of the disease including stricture or abdominal abscess. When surgery is necessary, maintenance medications administered postoperatively will postpone recurrence. Patients with UC and CD are at risk for the development of micronutrient deficiencies (including folate, iron, and vitamin D deficiencies) and require close nutritional monitoring. In addition, patients with UC and CD involving the colon are at increased risk of developing colon cancer, and should be enrolled into a colonoscopy surveillance program after 8-10 years of disease duration.

Update in the treatment of paediatric ulcerative colitis

Ulcerative colitis is an important disease in the paediatric population. Ulcerative colitis is one of the chronic inflammatory bowel diseases, and is medically incurable. However, the arsenal of medications has grown as knowledge of the pathogenesis of this disease advances. This review looks at the classical treatments for children with ulcerative colitis, including the 5-aminosalicylates, corticosteroids and imunomodulators, as well as biological therapy and other, newer modalities.

Azathioprine in dermatology: The past, the present, and the future

For several decades, dermatologists have utilized azathioprine to treat numerous debilitating skin diseases. This synthetic purine analog is derived from 6-mercaptopurine. It is thought to act by disrupting nucleic acid synthesis and has recently been found to interfere with T-cell activation. The most recognized uses of azathioprine in dermatology are for immunobullous diseases, generalized eczematous disorders, and photodermatoses. In this comprehensive review, the authors present recent advancements in the understanding of azathioprine and address aspects not covered in prior reviews. They (1) summarize the history of azathioprine; (2) discuss metabolism, integrating information from recent publications; (3) review the mechanism of action with attention paid to the activities of azathioprine not mediated by its 6-mercaptopurine metabolites and review new data about inhibition by azathioprine of the CD28 signal transduction pathway; (4) thoroughly examine thiopurine s-methyltransferase genetics, its clinical relevance, and interethnic variations; (5) review prior uses of azathioprine in the field of dermatology and grade the level of evidence; (6) discuss the use of azathioprine in pregnancy and pediatrics; review (7) key drug interactions and (8) adverse effects; (9) suggest a dosing and monitoring approach different from prior recommendations; and (10) explore the future of azathioprine, focusing on laboratory considerations and therapeutic application.

Infliximab efficacy in pediatric ulcerative colitis

BACKGROUND

The effects of infliximab, a tumor necrosis factor-alpha (TNF-alpha) antibody, have been well established in adult patients with inflammatory and fistulizing Crohn's disease. This study evaluates short- and long-term efficacy of infliximab in children with ulcerative colitis.

METHODS

All pediatric patients with ulcerative colitis who received infliximab between July 2001 and November 2003 at the Johns Hopkins Children's Center were identified. Short- and long-term outcomes and adverse reactions were evaluated.

RESULTS

Twelve pediatric patients with ulcerative colitis received infliximab for treatment of fulminant colitis (3 patients), acute exacerbation of colitis (3), steroid-dependent colitis (5), and steroid-refractory colitis (1). Nine patients had a complete short-term response, and 3 had partial improvement. The mean per patient dose of corticosteroid after the first infliximab infusion decreased from 45 mg/day at the first infusion to 22.2 mg/day at 4 weeks (P = 0.02) and 7.8 mg/day at 8 weeks (P = 0.008). Eight patients were classified as long-term responders with a median follow-up time of 10.4 months. Of the 4 long-term nonresponders, 3 underwent colectomy, and the fourth has ongoing chronic symptoms. Three of 4 long-term nonresponders were steroid-refractory compared with 1 of 8 long-term responders. Patients receiving 6-mercaptopurine had a better response to infliximab.

CONCLUSION

Infliximab should be considered in the treatment of children with symptoms of acute moderate to severe ulcerative colitis.

Utility of measuring 6-methylmercaptopurine and 6-thioguanine nucleotide levels in managing inflammatory bowel disease patients treated with 6-mercaptopurine in a clinical practice setting

BACKGROUND

Measuring levels of 6-mercaptopurine (6-MP) metabolites (6-thioguanine nucleotides [6-TGNs] and 6-methylmercaptopurine [6-MMP]) has been proposed as a method to adjust 6-MP dose to optimize therapeutic response while minimizing toxicity in patients with inflammatory bowel disease. A 6-TGN level of >230 pmol/8 x 108 red blood cells (RBCs) has been reported to be associated with a higher efficacy rate, and a level of >450 pmol/8 x 108 RBCs has been reported to be associated with myelotoxicity. A 6-MMP level of >5,700 pmol/8 x 108 RBCs has been reported to be associated with an increased frequency of abnormal results of liver function tests (LFTs).

GOALS

To report our experience with 6-MMP and 6-TGN levels in a clinical practice setting.

STUDY

Using outpatient clinic medical records, we identified 53 measurements. Indications for measurement, 6-MP dose, and subsequent adjustments were documented.

RESULTS

Indications for measurements included the following: persistent symptoms, 31 cases (58.5%); abnormal LFT results, 7 (13.2%); steroid dependency, 6 (11.3%); anemia, 4 (7.5%); and leukopenia, 2 (3.8%). Of the 31 cases with persistent symptoms, 12 had "therapeutic" 6-TGN levels and other interventions were undertaken. 6-TGN levels were "subtherapeutic" in 19. The 6-MP dose was increased, and remission was achieved in 10 cases after a mean period of 3.6 weeks. Among the cases with abnormal LFT results, 6-MMP levels were high in five and low in two. Among the steroid dependency cases, 6-TGN levels were "subtherapeutic" in five. The dose was increased and steroids were weaned in three cases. The 6-TGN level was high in one of the leukopenia cases and the 6-MP dose was decreased. 6-TGN levels were not above the "target range" in any of the anemia cases.

CONCLUSION

Measuring levels of 6-MP metabolites may have a role in customizing 6-MP dosing. This role is not completely clear and needs to be explored in larger well-controlled studies.

Ulcerative colitis in children: medical management

Ulcerative colitis is a chronic relapsing inflammatory disorder of the colonic mucosa of unknown etiology. The inflammatory process involves the mucosa and submucosa in a continuous segment of bowel with rectal involvement in almost all cases. Since its etiology is unknown, therapy is directed at modulating the inflammatory response in order to control symptoms and to prevent relapses. 5-aminosalicylates and corticosteroids have been the most widely used therapeutic agents for treatment of ulcerative colitis. Recently, experience has been gained with the use of other immunomodulators, such as mercaptopurine, azathioprine, methotrexate, cyclosporine, and tacrolimus, in pediatric patients. Colectomy is indicated in patients with severe colitis who do not respond to intensive medical therapy. The care of children with ulcerative colitis not only involves control of symptoms from gastrointestinal and extraintestinal manifestations, but also optimizing growth and development. The complications of chronic inflammation and long-term medical therapy must be weighed against the risks and benefits of surgery for children and adolescents with this condition.

Treatment of inflammatory bowel disease in childhood: best available evidence

The physician treating children with inflammatory bowel disease is confronted with a number of specific problems, one of them being the lack of randomized, controlled drug trials in children. In this review, the role of nutritional therapy is discussed with a focus on primary treatment, especially for children with Crohn's disease. Then, the available medical therapies are highlighted, reviewing the evidence of effectiveness and side effects in children, as compared with what is known in adults. Nutritional therapy has proven to be effective in inducing and maintaining remission in Crohn's disease while promoting linear growth. Conventional treatment consists of aminosalicylates and corticosteroids, whereas the early introduction of immunosuppressives (such as azathioprine or 6-mercaptopurine) is advocated as maintenance treatment. If these drugs are not tolerated or are ineffective, methotrexate may serve as an alternative in Crohn's disease. Cyclosporine is an effective rescue therapy in severe ulcerative colitis, but only will postpone surgery. A novel strategy to treat Crohn's disease is offered by infliximab, a monoclonal antibody to the proinflammatory cytokine tumor necrosis factor (TNF)-alpha. Based on the best-available evidence, suggested usage is provided for separate drugs with respect to dosage and monitoring of side effects in children.

Azathioprine in paediatric inflammatory bowel disease: an Italian multicentre survey

AIM

To assess the efficacy and safety of azathioprine in a paediatric population with inflammatory bowel disease.

PATIENTS AND METHODS

One hundred and twenty-three Italian children treated with azathioprine were studied retrospectively. The treatment duration and causes of its discontinuation, side-effects and variation in corticosteroid dose were assessed.

RESULTS

The mean age at inflammatory bowel disease diagnosis was 9.8 +/- 3.6 years, and at the start of azathioprine therapy 11.8 +/- 4.3 years. The mean duration of treatment was 19 +/- 16 months. Fifty patients (41%) stopped treatment due to surgery (12%), prolonged remission (11%), non-response (7%), severe side-effects (7%) and poor compliance (3%). Of the 73 patients (59%) remaining on azathioprine, 11 had never been treated with corticosteroids, 27 were able to stop them and 35 were still on a very low daily dose (91% < 0.3 mg/kg). The difference in the daily corticosteroid dose between the beginning of azathioprine treatment (1 +/- 0.6 mg/kg) and the conclusion of the study (0.18 +/- 0.16 mg/kg) was statistically significant. Side-effects were recorded in 48 of the 123 patients (39%), but only eight required discontinuation of azathioprine.

CONCLUSIONS

Azathioprine was efficacious in 70% of patients, but ineffective in 20% and induced severe toxicity in 7%. Corticosteroids were stopped or markedly reduced in 62% of patients, but they were never given in 9%.

Immunomodulatory therapy for pediatric inflammatory bowel disease: changing patterns of use, 1990-2000

OBJECTIVE

To identify changes over the past decade in physicians' attitudes regarding the use of immunomodulatory agents for the treatment of children with inflammatory bowel disease (IBD), we surveyed the membership of the North American Society for Pediatric Gastroenterology and Nutrition and compared the responses to those from an identical survey performed in 1990.

METHODS

Surveys were mailed to 718 physicians in January, 2000. All surveys returned by mid-February were analyzed, and results compared to those obtained in the 1990 survey.

RESULTS

Thirty-nine percent (278/718) of surveys were returned, compared to 27% (105/385) in 1990. Overall, 93% of the current survey's respondents agreed with the statement "immunomodulatory agents are effective in the treatment of children and adolescents with IBD." Compared to 1990, significant increases (p < 0.0001) were noted in the percentage of respondents who prescribe immunomodulatory agents to children with all forms of IBD. Indications for immunomodulation that showed significant increases (p < 0.001) since 1990 included treatment of perianal and non-perianal fistulae; growth failure; use as initial, primary therapy; and use as prophylaxis against postoperative recurrence. 6-Mercaptopurine and azathioprine continue to be the agents prescribed by the greatest percentage of respondents. More physicians are willing to use immunomodulatory agents in children younger than 5 yr, and duration of use is longer than in 1990. Currently, physicians seem to favor the use of immunomodulatory agents over colectomy for children with either intractable ulcerative or Crohn's colitis. Most respondents remain concerned about potential bone marrow and immune suppression, but concerns regarding malignancy, teratogenicity, and infertility have lessened.

CONCLUSION

These survey findings document that pediatric gastroenterologists have widely accepted the use of immunomodulators in the treatment of children and adolescents with IBD.

Update in medical therapy of ulcerative colitis: a practical approach

The bewildering array of medications in the therapy of inflammatory bowel disease (IBD) often confounds the clinician in the choice of specific agents regarding the balance between safety and efficacy. This review surveys and evaluates currently available IBD therapies as well as those used in clinical trials of ulcerative colitis. The primary purpose is to provide the busy clinician with a practical guide to the use of established and newly emerging medical therapies of IBD.

Severe life-threatening diarrhea caused by azathioprine but not by 6-mercaptopurine

Azathioprine and its active metabolite 6-mercaptopurine are of increasing importance in the treatment of chronic inflammatory bowel disease. Most of the toxicity and the side effects of the medications are well known. However, it is relatively unknown that azathioprine toxicity itself can produce devastating diarrhea in patients with inflammatory bowel disease. This leads to great difficulties in differential diagnosis. We describe 2 patients with severe intestinal toxicity. This was life-threatening in 1 patient after reintroducing the drug. We therefore believe that any rechallenge with azathioprine should be only undertaken in a controlled hospital environment when a reaction to azathioprine is suspected. In addition, we found that this devastating intestinal toxicity did not reoccur after rechallenge with its active metabolite 6-mercaptopurine. Azathioprine and 6-mercaptopurine therefore cannot be used interchangeably.

6-mercaptopurine metabolite levels in children with inflammatory bowel disease

OBJECTIVES

Some authors suggest that efficacy of 6-mercaptopurine (6-MP) in patients with inflammatory bowel disease correlates with circulating 6-thioguanine (6-TG) levels more than 235 pmol/8 x 10(8) red blood cells. The authors evaluated the relation between 6-MP metabolite levels and disease activity in children and adolescents with inflammatory bowel disease.

METHODS

Clinical status and hematologic and hepatic parameters were determined in 101 children with inflammatory bowel disease from a single center and compared with 6-MP metabolite levels.

RESULTS

There was a trend for higher 6-TG levels among patients in remission than among those with active disease (217 vs. 173); however the difference was not statistically significant ( P = 0.09). The likelihood of therapeutic response did not increase significantly at 6-TG levels greater than 235 pmol/8 x 10(8) red blood cells (odds ratio 1.7; P = 0.1). In the current study, 58% of patients in remission had 6-TG levels less than 235. However, serial measurements of 6-MP metabolite levels in 50 patients with active disease showed that increasing 6-TG levels correlated significantly with disease remission in patients followed up longitudinally ( P = 0.04). Leukopenia was significantly associated with high 6-TG levels ( P = 0.03) but not with clinical response ( P = 0.2).

CONCLUSIONS

These data suggest that the target range of 6-TG levels previously described by others did not apply to 58% of the pediatric patients with IBD in remission. However, serial monitoring of 6-MP metabolite levels in individual patients with active disease should allow dose escalation and induction of remission while minimizing the risk of toxicity.

A Perspective on inflammatory bowel disease in the child and adolescent at the turn of the millennium

The literature of the past year has produced significant advances relevant to the diagnosis and treatment of children and adolescents with inflammatory bowel disease. This review focuses on new observations regarding the epidemiology, genetics, etiology, diagnosis, and treatment of both Crohn's disease and ulcerative colitis in children. Particular attention is paid to the expanded indications for the use of immunomodulatory therapy, and to the early published data regarding the safety and efficacy of treatment with infliximab.

Pediatric Inflammatory Bowel Disease

The combination of an unprecedented number of new therapeutic options (Fig. 1), along with new insights in how to optimize currently available therapies and advances in our understanding of disease pathogenesis, present many exciting new aspects to the management of patients with inflammatory bowel disease (IBD). Clinical management paradigms must evolve in parallel to keep pace with these advances. Traditional pediatric IBD regimens have underutilized combination therapies (Fig. 2) and immunomodulatory agents. Increased appreciation for steroid side effects is leading to a shift away from their inclusion in maintenance regimens. Immunomodulators are being introduced earlier in the course of disease for maintenance of remission and growth promotion. Recognition that the sole signs of active disease in children and adolescents may be growth and maturational delay, despite a relative lack of gastrointestinal symptoms, should prompt earlier, more aggressive interventions. When more potent, rapidly acting interventions such as infliximab, cyclosporine (CSA), or tacrolimus are considered, they should generally be co-administered with agents such as 6-mercaptopurine (6-MP) or azathioprine (AZA) for longer-term disease suppression.

Normal thiopurine methyltransferase levels do not eliminate 6-mercaptopurine or azathioprine toxicity in children with inflammatory bowel disease

6-mercaptopurine (6-MP) and azathioprine (AZA) are used to treat inflammatory bowel disease (IBD). Side effects include infection, leukopenia, hepatitis, and pancreatitis. The level of thiopurine methyltransferase (TPMT), which metabolizes 6-MP to 6-methylmercaptopurine, may reflect the risk of side effects. We sought to evaluate the relationship between the side effects of these medications and the TPMT level of pediatric patients with IBD. The medical records of our patients who were diagnosed with IBD and who received 6-MP or AZA were reviewed for measured TPMT levels. All red blood cell (RBC) TPMT levels were determined at the Mayo Medical Laboratories, Rochester, MN. The occurrence of leukopenia, elevated aminotransferases, and pancreatitis was evaluated. Twenty-two patients, mean age 13.7 years, received 6-MP or AZA and had TPMT levels measured. The TPMT levels ranged 10.7-27.5 U/mL RBC with a mean of 17.2 +/- 3.2 U/mL RBC. Two children had levels below the accepted norm of 13.8 U/mL RBC. One of these patients (50%) developed both elevation of aminotransferases and leukopenia. Of all, 20 children had normal levels, 3 (15.0%) exhibited side effects: hepatitis (n = 2) and leukopenia (n = 1). We conclude that side effects of 6-MP or AZA occur despite normal TPMT levels.

Predicting the need for colectomy in pediatric patients with ulcerative colitis

Total colectomy is curative for ulcerative colitis. However, many pediatric patients are medically managed and may not require surgery. There are currently no available criteria to identify children who will benefit from early colectomy. The purpose of this review was to identify criteria associated with the need for colectomy. A 15-year review of patients at a major pediatric center with biopsy-proved ulcerative colitis was conducted. Age at the time of the first symptom, diagnosis, and surgery were recorded as well as steroid dependence, site of disease, extraintestinal manifestations, and family history. Seventy-three patients ranging in age from 1 to 18 years were identified. Thirty-seven patients (50.1%) required total colectomy before the age of 18. The average patient age at the time of the first documented symptom was 11.3 +/- 0.5 years. Among patients who were steroid dependent and had pancolitis, 73% required colectomy. Patients with these factors failed medical management 77% (27 of 35) of the time, and colectomy was performed within 3 years of diagnosis. The combination of steroid dependence and pancolitis was associated with an increased need for colectomy. In pediatric patients with these factors, early colectomy may limit the need to endure prolonged courses of medications and the disability allied with this disease.

Novel immunosuppressive therapies for intestinal and hepatic diseases

Recent advances in the understanding of the pathogenesis of immune-mediated hepatic and intestinal diseases have led to major therapeutic advances. The introduction of genetically engineered biologic agents specifically designed to target inflammatory mediators responsible for the perpetuation of chronic inflammatory processes is a novel example. Although corticosteroids remain important as a first-line therapeutic option for active inflammatory bowel disease, approximately one third and one fifth of patients develop steroid dependence and resistance, respectively. From a pediatric perspective, a major advance has thus been the advocation of prolonged immunosuppressive therapy with 6-mercaptopurine or azathioprine for children with inflammatory bowel disease. The introduction of effective steroid-sparing agents for the induction and maintenance of remission is a key management issue. The past year has also witnessed the increased utilization of powerful immunosuppressive agents with rapid onset of action, such as cyclosporine and tacrolimus, in patients resistant to conventional therapies. This review will afford pediatricians a sense of what to expect for the management of hepatic and intestinal disorders with immunosuppression as we advance into the new millenium.

Inflammatory bowel disease in pediatric and adolescent patients

IBD is a chronic pediatric disease that needs to be treated by a team of experts consisting of pediatricians, pediatric gastroenterologists, psychologists, nutritionists, social workers, and nurses. A critical factor in successful management of this disease is the willingness of the patient to participate and cooperate with the team. Parents and patients must be educated and supported to treat these disorders effectively. Much further research is necessary to understand the specific causative and therapeutic issues unique to young patients with IBD.