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Sigall Boneh R, Westoby C, Oseran I, Sarbagili-Shabat C, Albenberg LG, Lionetti P, Manuel Navas-López V, Martín-de-Carpi J, Yanai H, Maharshak N, Van Limbergen J, Wine E. The Crohn's Disease Exclusion Diet: A Comprehensive Review of Evidence, Implementation Strategies, Practical Guidance, and Future Directions. Inflamm Bowel Dis 2023:izad255. [PMID: 37978895 DOI: 10.1093/ibd/izad255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Indexed: 11/19/2023]
Abstract
Dietary therapy is increasingly recognized for the management of Crohn's disease (CD) over recent years, including the use of exclusive enteral nutrition (EEN) as first-line therapy for pediatric CD according to current guidelines. The Crohn's disease exclusion diet (CDED) is a whole-food diet designed to reduce exposure to dietary components that are potentially pro-inflammatory, mediated by negative effects on the gut microbiota, immune response, and the intestinal barrier. The CDED has emerged as a valid alternative to EEN with cumulative evidence, including randomized controlled trials, supporting use for induction of remission and possibly maintenance in children and adults. We gathered a group of multidisciplinary experts, including pediatric and adult gastroenterologists, inflammatory bowel diseases (IBD) expert dietitians, and a psychologist to discuss the evidence, identify gaps, and provide insights into improving the use of CDED based on a comprehensive review of CDED literature and professional experience. This article reviews the management of CDED in both children and adults, long-term aspects of CDED, indications and contraindications, selecting the best candidates, identifying challenges with CDED, globalization, the role of the multidisciplinary team, especially of dietitian, and future directions. We concluded that CDED is an established dietary therapy that could serve as an alternative to EEN in many pediatric and adult cases, especially with mild to moderate disease. In severe disease, complicated phenotypes, or with extraintestinal involvement, CDED should be considered on a case-by-case basis, according to physician and dietitians' discretion. More studies are warranted to assess the efficacy of CDED in different scenarios.
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Affiliation(s)
- Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Catherine Westoby
- Department of Nutrition and Dietetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ilan Oseran
- Department of Psychology, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Chen Sarbagili-Shabat
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lindsey G Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Paolo Lionetti
- Department Neurofarba, University of Florence, Meyer children's Hospital IRCCS, Florence, Italy
| | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit. Hospital Regional Universitario de Málaga. IBIMA. Málaga, Spain
| | - Javier Martín-de-Carpi
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Henit Yanai
- IBD center, Division of Gastroenterology, Rabin Medical center, Petach Tikva, Israel; affiliated with the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitsan Maharshak
- Tel Aviv Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johan Van Limbergen
- Department of Paediatric Gastroenterology and Nutrition, Amsterdam University Medical Centers, Emma Children's Hospital, Amsterdam, the Netherlands
- Amsterdam Public Health research institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Eytan Wine
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Young DD, Perry S, Malay S, Sferra TJ, Finkler M, Moses J. Natural History of Pediatric Patients With Crohn's Disease Treated With Mesalamine Therapy. JPGN REPORTS 2023; 4:e379. [PMID: 38034435 PMCID: PMC10684219 DOI: 10.1097/pg9.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 08/10/2023] [Indexed: 12/02/2023]
Abstract
Background 5-aminosalicylates (5-ASA) are used to treat mild to moderate ulcerative colitis. Despite their lack of efficacy in Crohn disease (CD), they are still used in real-world practice. Additionally, when patients have progressive disease, they may escalate to biologic therapy, at which time 5-ASA may or may not be discontinued. Objectives The aim of this study is to assess the clinical outcomes of patients started on 5-ASA for the treatment of pediatric CD. The secondary aims were to evaluate the outcomes of those who continue 5-ASA to those who discontinue 5-ASA upon biologic escalation. Methods We performed a single-center retrospective chart review of pediatric CD patients from 2010 to 2019 who were initially treated with 5-ASA. Demographics, medication and laboratory data, and clinical disease activity were collected. Results Sixty-one patients were included in the study; the majority had inflammatory CD with ileocolonic involvement. Twenty-four patients were on a concomitant immunomodulator. The majority of patients (85.2%) required escalation to biologics. Thirty-two patients (61.5%) who escalated to biologic therapy continued on 5-ASA. Eighty percent of patients achieved clinical remission at 1 year, and there was no difference between those who continued 5-ASA at time of biologic initiation compared to those who did not continue the medication. Patients who discontinued 5-ASA had an average annual cost savings of $6741. Conclusion 5-ASA is not a durable monotherapy for the treatment of pediatric CD. Patients who require escalation from 5-ASA to biologic therapy do not benefit from concomitant 5-ASA therapy. Further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Denise D. Young
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Sharon Perry
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Sindhoosha Malay
- Biostastics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Thomas J. Sferra
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Michael Finkler
- Department of Pediatric Pharmacy, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Jonathan Moses
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
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3
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Luo J, Xie YM, Wu M, Zhao JG, Hu LL. Global attitudes on and the status of enteral nutrition therapy for pediatric inflammatory bowel disease. Front Med (Lausanne) 2022; 9:1036793. [PMID: 36569124 PMCID: PMC9773139 DOI: 10.3389/fmed.2022.1036793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Enteral nutrition (EN) is a diet-remission therapy for inflammatory bowel disease (IBD) that plays a more important role in children than adults. EN includes exclusive enteral nutrition (EEN), partial enteral nutrition (PEN), and maintenance enteral nutrition (MEN). However, EEN remains an unstandardized treatment for pediatric IBD. The types and methods of EN differ around the world. The current study reviewed the EN literature on children with IBD. A total of 12 survey studies were identified that analyzed the current state of EN use, including clinical opinions, implementation methods, treatment course, EEN formula, IBD classification, progress, dietary reintroduction, and patient feedback. The findings revealed that EEN has a strong effect on mild to moderate Crohn's disease (CD). The usage rates of this treatment in different sites were ileum/colon (Paris classification L3) > ileum (L1) > upper digestive tract (L4) > colon (L2) > perianal disease (P) > ulcerative colitis (UC) > extraintestinal lesions. The polymeric formula was the most used EN formulation. New EN diets include a CD exclusion diet (CDED), a specific carbohydrate diet (SCD), and a CD treatment-with-eating (CD-TREAT) diet. Children with IBD responded similarly to EEN administered orally or using a feeding tube. Most guidelines recommended 6-8 weeks of EEN treatment to induce remission. Many clinicians preferred to combine drug medications during EEN and recommended that MEN accounts for at least 25-35% of daily caloric intake. EN remains an unstandardized therapy that requires teamwork across disciplines.
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Affiliation(s)
- Juan Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Yong-Mei Xie
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China,*Correspondence: Yong-Mei Xie,
| | - Mei Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Jin-Gui Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Liang-Liang Hu
- Department of Pediatrics, Luzhou People’s Hospital, Luzhou, Sichuan, China
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Peters S, Cantez S, De Laffolie J. Implementation of exclusive enteral nutrition in pediatric patients with Crohn's disease-results of a survey of CEDATA-GPGE reporting centers. Mol Cell Pediatr 2022; 9:6. [PMID: 35381916 PMCID: PMC8982684 DOI: 10.1186/s40348-022-00139-x] [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] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/17/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is the first-line therapy for pediatric-onset Crohn's disease (CD) patients. CEDATA-GPGE® is the largest patient registry for children and adolescents with inflammatory bowel disease (IBD) in Europe, collecting data from over 5000 patients since 2004 in Germany and Austria. Since the application of EEN over 8 weeks is difficult and a high dropout rate is often described, the mode of application including a supporting structure is crucial for success. The aim of this study was to ascertain the variation in the application of EEN across the participating centers and to associate these with the outcome. RESULTS Thirty-one centers responded to the survey (81.6%). 88.5% of CD patients were recommended EEN for induction therapy, 71.8% actually started with EEN, and 22.1% terminated the EEN prematurely. The duration of EEN typically lasted 6 to 8 weeks, and the polymeric formula was mainly used. 80.6% of the clinics added flavorings to the formulas. After EEN, the most preferred diet for maintenance therapy was a healthy, well-balanced diet considering individual intolerances. CONCLUSIONS EEN is widely recommended as an induction therapy by the German and Austrian pediatric gastroenterologists for children and adolescents with CD. However, this questionnaire-based study has shown a wide variation in EEN protocols used by the different pediatric clinics of CEDATA-GPGE®.
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Affiliation(s)
- Sarah Peters
- Institut für Ernährungswissenschaft, Justus-Liebig-Universität, Giessen, Germany.
| | - Serdar Cantez
- Department for General Pediatrics & Neonatology, University Hospital Giessen, Giessen, Germany
| | - Jan De Laffolie
- Department for General Pediatrics & Neonatology, University Hospital Giessen, Giessen, Germany
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Balart MT, Russell L, Narula N, Bajaj G, Chauhan U, Khan KJ, Marwaha AN, Ching E, Biro J, Halder S, Tse F, Marshall JK, Collins SM, Moayyedi P, Bercik P, Verdu EF, Leontiadis GI, Armstrong D, Pinto-Sanchez MI. Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial. J Can Assoc Gastroenterol 2021; 4:214-221. [PMID: 34617003 PMCID: PMC8489529 DOI: 10.1093/jcag/gwaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Corticosteroids (CS) have been used extensively to induce remission in Crohn’s disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks. Aim The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN Methods The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN. Results A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment. Conclusion The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.
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Affiliation(s)
- M T Balart
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - L Russell
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - N Narula
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - G Bajaj
- McMaster University Medical Centre, Hamilton, ON, Canada.,Brampton Endoscopy Centre, Brampton, ON, Canada
| | - U Chauhan
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada
| | - K J Khan
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada.,St. Joseph's Health Care Centre, Hamilton, ON, Canada
| | | | - E Ching
- GI Health Centre, Burlington, ON, Canada
| | - J Biro
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - S Halder
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - F Tse
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - J K Marshall
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - S M Collins
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - P Moayyedi
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - P Bercik
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - E F Verdu
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - G I Leontiadis
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - D Armstrong
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - M I Pinto-Sanchez
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
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6
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Parent Perspectives on Exclusive Enteral Nutrition for the Treatment of Pediatric Crohn Disease. J Pediatr Gastroenterol Nutr 2020; 71:744-748. [PMID: 32910623 DOI: 10.1097/mpg.0000000000002847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Exclusive enteral nutrition (EEN) is infrequently used in the United States but is an effective treatment for pediatric Crohn disease (CD). Limited data exists regarding patient and parent perspectives on this treatment modality. The aim of this study was to determine parent and provider perspectives regarding EEN and understand parent-cited barriers to its use. METHODS We surveyed the parents/guardians of children ages 1 through 17 with CD in our institution regarding EEN. Healthcare provider perspectives regarding reason for stopping EEN and those cited by survey respondents were compared using retrospective chart review. RESULTS One hundred fifteen (62.5%) out of 184 recipients responded to the survey. Ninety percentage of respondents had heard of EEN but of these, 26% had not discussed it with their gastroenterologist. Thirty-eight patients (33%) were treated in the past and 15 (13%) were currently on EEN. Common barriers cited by current EEN users were cost/finances and difficult social situations. Of the children who stopped EEN, most did so as parents felt it was not working (n = 14, 37%). In these cases, their primary gastroenterologist cited treatment failure for 4 cases and nonadherence for 6. CONCLUSIONS Despite the efficacy of EEN and interest in dietary treatments by patients with CD, there are many barriers surrounding effective communication and successful implementation of dietary therapies. Future research is needed regarding patient-physician communication, cost mitigation, and coping with the social limitations of dietary therapies.
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7
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Yang H, Feng R, Li T, Xu S, Hao X, Qiu Y, Chen M. Systematic review with meta-analysis of partial enteral nutrition for the maintenance of remission in Crohn's disease. Nutr Res 2020; 81:7-18. [PMID: 32798791 DOI: 10.1016/j.nutres.2020.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 12/28/2022]
Abstract
Although enteral nutrition (EN) is effective for induction therapy in Crohn's disease (CD), it remains unclear whether partial enteral nutrition (PEN), i.e., EN, along with a daily diet, is effective for maintenance therapy in CD. It was hypothesized that PEN would be effective as a maintenance therapy in CD. This meta-analysis aimed to evaluate the efficacy and safety of PEN for maintenance therapy in CD. PubMed, EMBASE, Web of Science, and Cochrane Library were searched up to January 2019 for eligible prospective controlled trials, and then a meta-analysis was conducted. The primary outcome was clinical relapse, as defined in the primary studies. Eight studies with 429 patients were included in the meta-analysis. The rate of clinical relapse at 0.5 to 2 years was significantly lower in patients receiving PEN (420-1800 kcal/d) than in those not receiving nutrition therapy (RR: 0.67, 95% CI: 0.54-0.82, P < .01; number needed to treat = 5, P < .01). Patients receiving PEN exhibited a higher frequency of clinical remission maintenance at 0.5 to 1 year (67%) than did those not receiving nutrition therapy (48%; RR: 1.32, 95% CI: 1.07-1.64, P = .01). The total adverse event rate was comparable in the two groups (RR: 3.60, 95% CI: 0.70-18.66, P = .13). PEN may be more effective than the absence of EN therapy for the maintenance of remission in CD with a good safety profile.
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Affiliation(s)
- Hongsheng Yang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26 Yuancun Road II, Tianhe district, Guangzhou 510000, P.R. China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Shu Xu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Xiuxue Hao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China.
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China.
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8
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Zimmerman L, Bousvaros A. The pharmacotherapeutic management of pediatric Crohn's disease. Expert Opin Pharmacother 2019; 20:2161-2168. [PMID: 31574236 DOI: 10.1080/14656566.2019.1659778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Crohn's disease (CD) is a chronic inflammatory condition that can occur throughout the gastrointestinal tract. The aims of treatment of children with CD are to induce and maintain clinical remission of disease, optimize nutrition and growth, minimize adverse effects of therapies, and if possible, achieve mucosal healing.Areas covered: This review summarizes evidence for the various therapeutic options in the treatment of children with CD. Exclusive enteral nutrition, corticosteroids, and biologics may be used for induction of remission. Immunomodulators (thiopurines, methotrexate) and biologics (infliximab, adalimumab) may be employed for maintenance of remission to prevent flares of disease and avoid chronic steroid use. In cases of fibrotic disease, intestinal perforations, or medically refractory, surgery may be the best therapeutic option.Expert opinion: Exclusive enteral nutrition, corticosteroids, and biologics (including anti-TNF inhibitors) may be used for induction of remission in patients with active flare of their disease. Immunomodulators and TNF inhibitors may be used for maintenance of remission. Early use of anti-TNF inhibitors in patients with moderate to severe CD may improve efficacy and prevent penetrating complications of disease. While pediatric data is limited, newer biologics, such as vedolizumab and ustekinumab, are used off-label in anti-TNF refractory disease.
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Affiliation(s)
- Lori Zimmerman
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Harvard Medical School, Boston, MA, USA
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Harvard Medical School, Boston, MA, USA
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Liu J, Andrews JM, Sammour T, Bryant RV, Grafton R, Simpson E, Putrus E, Nixon C. Benefits of Exclusive Enteral Nutrition in Adults With Complex Active Crohn’s Disease: A Case Series of 13 Consecutive Patients. CROHN'S & COLITIS 360 2019. [DOI: 10.1093/crocol/otz044] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Immunosuppressive therapy is routine for adults with complex active Crohn’s disease (CD), however carries risks, particularly in the setting of sepsis. Exclusive enteral nutrition (EEN) is widely used in paediatric CD, yet efficacy data in adults are sparse. This study evaluated outcomes of EEN in adults with complex active CD.
Methods
Between December 2016 and June 2018, 13 patients with complex active CD (range 20–74 years) managed at a single hospital received 2 or more weeks of EEN. Patients were offered EEN based on either malnutrition, contraindication to immunosuppression, or CD refractory to multiple therapies. Subjective and objective outcomes were recorded at 2 and 6 weeks and compared with baseline data.
Results
Nine of 13 patients experienced subjective improvement in wellbeing. Objective improvements included nine CRP decrements (median = 87.7 mg/L, IQR = 70.6 mg/L), nine serum albumin increments (median = 7 g/L, IQR = 4 g/L), and six gained weight (median = 3.6 kg, IQR = 3.0 kg). All five patients with complex abscess resolved without surgery. One ileocolic fistula and one enterocutaneous fistula achieved resolution without surgery. One of two perianal fistulae cases resolved without surgery. Seven of 10 patients initially thought to need surgery avoided it due to disease resolution. Only one of the three patients who proceeded to surgery sustained a post-operative complication. There were no EEN-associated complications.
Conclusions
In complex active CD, our real-world data show that EEN improves wellbeing, decreases inflammatory markers, leads to healthy weight gain, reduces need for surgical intervention, and reduces postoperative complications.
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Affiliation(s)
- Jianliang Liu
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Jane M Andrews
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Robert V Bryant
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Rachel Grafton
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eliza Simpson
- Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Emma Putrus
- Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Claire Nixon
- Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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10
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Di Caro S, Fragkos KC, Keetarut K, Koo HF, Sebepos-Rogers G, Saravanapavan H, Barragry J, Rogers J, Mehta SJ, Rahman F. Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift. Nutrients 2019; 11:E2222. [PMID: 31540038 PMCID: PMC6770416 DOI: 10.3390/nu11092222] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.
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Affiliation(s)
- Simona Di Caro
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Konstantinos C Fragkos
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Katie Keetarut
- Department of Dietetics, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hui Fen Koo
- UCL Medical School, 74 Huntley Street, Bloomsbury, London WC1E 6DE, UK.
| | - Gregory Sebepos-Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hajeena Saravanapavan
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - John Barragry
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Jennifer Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Shameer J Mehta
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Farooq Rahman
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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Ho SSC, Day AS. Exclusive enteral nutrition in children with inflammatory bowel disease: Physician perspectives and practice. JGH OPEN 2018; 3:148-153. [PMID: 31061890 PMCID: PMC6487830 DOI: 10.1002/jgh3.12121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/28/2018] [Accepted: 11/03/2018] [Indexed: 12/19/2022]
Abstract
Background and Aim Exclusive enteral nutrition (EEN) is recognized internationally as the first line of treatment for children with active Crohn's disease (CD). A survey conducted a decade ago demonstrated that 40% of Australian pediatric gastroenterologists did not think EEN to be an appropriate treatment for CD. This study aimed to explore the current attitudes of Australian and New Zealand (NZ) pediatric gastroenterologists toward the use of EEN in children with inflammatory bowel disease (IBD). Methods All practicing pediatric gastroenterologists in Australia and NZ were invited via an existing email network to complete an anonymous online questionnaire. Results The questionnaire was completed by 37 respondents (54% response rate), 31 from Australia and 6 from NZ. All respondents felt that EEN definitely or probably has a role in inducing remission for children with newly diagnosed CD. Australian gastroenterologists were more likely to use EEN for relapsed CD or IBD‐unclassified than NZ doctors (P < 0.05). Adherence was reported to be the greatest disadvantage of EEN. Dietitians were believed to play the most crucial role in EEN administration. Variations in EEN protocols included the use of flavorings or fluids during EEN and different patterns of food reintroduction. Conclusions These Australia and NZ pediatric gastroenterologists felt that EEN plays an important role in the induction of remission in children with newly diagnosed CD. However, the perceived role of EEN use in other types of IBD varied. EEN protocols varied widely between centers. Attitudes toward the roles of EEN have altered greatly across Australasia over the last decade.
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Affiliation(s)
- Shaun S C Ho
- Department of Paediatrics University of Otago Christchurch New Zealand
| | - Andrew S Day
- Department of Paediatrics University of Otago Christchurch New Zealand
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12
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Sokollik C, Fournier N, Rizzuti D, Braegger CP, Nydegger A, Schibli S, Spalinger J. The Use of 5-Aminosalicylic Acid in Children and Adolescents With Inflammatory Bowel Disease. J Clin Gastroenterol 2018. [PMID: 28644308 DOI: 10.1097/mcg.0000000000000864] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In ulcerative colitis (UC) 5-aminosalicylic acid (5-ASA) is recommended as primary therapy for mild to moderate disease. Topical 5-ASA has been proven especially effective. In Crohn's disease (CD) the evidence for a beneficial role of 5-ASA is weak. We investigated the use of topical and systemic 5-ASA therapy in children and adolescents with inflammatory bowel disease. MATERIALS AND METHODS Data of patients younger than 18 years, registered between April 2008 and December 2015 in the Swiss Inflammatory Bowel Disease Cohort, were analyzed. RESULTS Three hundred twenty pediatric inflammatory bowel disease patients were included; 189 with CD and 131 with UC. Over one third of UC patients [51 (39%)] received topical 5-ASA therapy and 43 (33%) received combination therapy during their disease course. UC patients with left-sided colitis or proctitis were more likely to receive topical or combination therapy as compared with patients with pancolitis (P<0.001 and <0.001, respectively). An increase in the use of topical 5-ASA therapy in UC patients was noted over time from 5% to 38%. Forty-seven percent of CD patients were treated with oral 5-ASA during their disease course. The usage was stable over time at approximately 15% to 20%. CONCLUSIONS In recent years a very positive trend showing an increase in topical 5-ASA therapy in children and adolescents with UC has been observed. However topical therapy is still used with relative low frequency, especially in patients with a more extensive disease. Conversely, despite weak evidence supporting 5-ASA use in CD patients it has been frequently prescribed. Physicians should continue to encourage their UC patients to use topical therapy.
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Affiliation(s)
- Christiane Sokollik
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital, University of Bern, Bern
| | - Nicolas Fournier
- Institute of Social and Preventive Medicine (IUMSP), University Hospital of Lausanne
| | - David Rizzuti
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital, University of Bern, Bern
| | - Christian P Braegger
- Division of Pediatric Gastroenterology and Nutrition and Children's Research Center, University Children's Hospital of Zurich, Zurich
| | - Andreas Nydegger
- Division of Pediatric Gastroenterology and Hepatology, University Hospital of Lausanne, Lausanne
| | - Susanne Schibli
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital, University of Bern, Bern
| | - Johannes Spalinger
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital, University of Bern, Bern.,Division of Pediatric Gastroenterology, Children's Hospital of Lucerne, Lucerne, Switzerland
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13
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Ramsey LB, Mizuno T, Vinks AA, Margolis PA. Learning Health Systems as Facilitators of Precision Medicine. Clin Pharmacol Ther 2018; 101:359-367. [PMID: 27984650 DOI: 10.1002/cpt.594] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 12/24/2022]
Affiliation(s)
- L B Ramsey
- Division of Research in Patient Services, Pharmacy Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - T Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - A A Vinks
- Division of Research in Patient Services, Pharmacy Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - P A Margolis
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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14
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Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease: Results and Outcomes. J Pediatr Gastroenterol Nutr 2018; 66:909-914. [PMID: 29315161 DOI: 10.1097/mpg.0000000000001879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Exclusive enteral nutrition (EEN) for induction of remission in children with Crohn disease (CD) is recommended as first-line therapy, but underutilized in the United States related to real and perceived barriers. We hypothesized that quality improvement (QI) methodology could increase use of EEN. METHODS We developed, implemented, and revised an algorithm and a set of tools to facilitate use of EEN. Through a series of Plan Do Study Act cycles, the approach was modified to overcome provider and patient/family barriers. The primary outcome, the percentage of newly diagnosed CD patients who receive EEN per month between July 2013 and October 2015, assessed using statistical process control. Secondary outcomes, including the short pediatric Crohn disease activity index (sPCDAI), body mass index (BMI) z score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after EEN. RESULTS Among patients newly diagnosed with CD, 73 patients initiated EEN and were included (mean age 12.7 ± 2.9 years, 49% girls, 86% white). Rates of utilization of EEN increased significantly from a baseline of <5% to an average of approximately 50%. Of the 73 patients who started EEN, 37 (50%) completed a minimum of 8 weeks. Of those completing therapy, 25 (71%) achieved remission, with a significant reduction of sPCDAI (33.6 ± 14.4 to 10.7 ± 12.3, P < 0.0001) CONCLUSIONS:: Use of QI methodology to systematically implement tools designed to improve utilization was effective in increasing the use of EEN. Among those completing therapy, EEN was effective in inducing remission.
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Narula N, Dhillon A, Zhang D, Sherlock ME, Tondeur M, Zachos M. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2018; 4:CD000542. [PMID: 29607496 PMCID: PMC6494406 DOI: 10.1002/14651858.cd000542.pub3] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta-analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. OBJECTIVES To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. SELECTION CRITERIA Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. DATA COLLECTION AND ANALYSIS Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random-effects model was used to pool data. We performed intention-to-treat and per-protocol analyses for the primary outcome. Heterogeneity was explored using the Chi2 and I2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. MAIN RESULTS Twenty-seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non-elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non-elemental diets differing in glutamine enrichment. Meta-analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty-four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non-elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per-protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non-elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating.Ten trials compared EN to steroid therapy. Meta-analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per-protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per-protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. AUTHORS' CONCLUSIONS Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy.
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Affiliation(s)
- Neeraj Narula
- McMaster UniversityDivision of Gastroenterology1280 Main Street WestHamiltonONCanadaL8S 4K1
| | - Amit Dhillon
- Northern Ontario School of MedicineDepartment of Internal MedicineSudburyONCanada
| | - Dongni Zhang
- University of Western OntarioSchulich School of Medicine & DentistryLondonONCanada
| | - Mary E Sherlock
- McMaster Children's HospitalDivision of Gastroenterology & NutritionHamilton Health Sciences1280 Main Street WestHamiltonONCanada
| | - Melody Tondeur
- The Hospital for Sick ChildrenCentre for Global Child Health525 University AveTorontoONCanadaM5G 2L3
| | - Mary Zachos
- McMaster Children’s HospitalDivision of Gastroenterology & Nutrition1280 Main St. WestHamiltonONCanadaL8S 4K1
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Shaikhkhalil AK, Crandall W. Enteral Nutrition for Pediatric Crohn's Disease: An Underutilized Therapy. Nutr Clin Pract 2018; 33:493-509. [PMID: 29446858 DOI: 10.1002/ncp.10011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Enteral nutrition (EN) for the treatment of Crohn's disease (CD) involves administration of a liquid nutrition product, administered orally or through tube feeding, while excluding typical dietary components. It is a safe and effective, but largely underused, therapy in the United States as a treatment for CD. EN is a particularly attractive option for pediatric CD as it avoids side effects of corticosteroids, improves growth, and may have a higher likelihood of achieving mucosal healing than some traditional medications. However, there are multiple real and perceived barriers to its use among providers. A comprehensive approach to addressing these barriers to EN may result in its increased use. This paper reviews the literature on the efficacy of EN, methods of utilization, and potential barriers and solutions to those barriers.
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Affiliation(s)
- Ala K Shaikhkhalil
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Wallace Crandall
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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17
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Ashton JJ, Gavin J, Beattie RM. Exclusive enteral nutrition in Crohn's disease: Evidence and practicalities. Clin Nutr 2018; 38:80-89. [PMID: 29398336 DOI: 10.1016/j.clnu.2018.01.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/08/2017] [Accepted: 01/11/2018] [Indexed: 12/19/2022]
Abstract
Exclusive enteral nutrition (EEN) is the first line therapy for paediatric Crohn's disease, providing a complete nutritional feed whilst simultaneously inducing remission in up to 80% of cases. The effect of EEN on systemic/local intestinal immune function and subsequent inflammation (including barrier permeability, direct anti-inflammatory effects and cytokine signalling pathways), alongside changes in the microbiome (specific species and broad taxonomic shifts, functional changes) are becoming clearer, however the exact mechanism for induction of remission in Crohn's disease remains uncertain. The evidence of efficacy in paediatric Crohn's disease is strong, with selected adult populations also benefiting from EEN. However despite recommendations from all major societies (ECCO, ESPGHAN, NASPGHAN and ESPEN) first-line use of EEN is varied and Europe/Australasia/Canada show significantly more routine use than other parts of North America. Growth and nutritional status are significantly improved with EEN compared to corticosteroids but long-term outcomes are sparse. This review discusses the evidence underlying the use of EEN, highlighting the mechanisms thought to underlie how EEN induces remission in Crohn's disease, when and how to use EEN, including practical issues in both paediatric and adult practice (formulation, compliance, volumes and administration), and summarises the ongoing research priorities.
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Affiliation(s)
- James J Ashton
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK; Human Genetics and Genomic Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Joan Gavin
- Department of Paediatric Dietetics, Southampton Children's Hospital, Southampton, UK
| | - R Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.
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18
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Senussi NH. Enteral Nutrition in the Treatment of Crohn's Disease: Overlooked and Underutilized. Am J Gastroenterol 2017; 112:1751-1752. [PMID: 29109488 DOI: 10.1038/ajg.2017.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Nizar H Senussi
- Liver Care Network, Swedish Medical Center, Seattle, Washington, USA
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19
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Feathers A, Swaminath A, Ananthakrishnan AN, Falzon L, Li Ferry S. Letter: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease-Authors' reply. Aliment Pharmacol Ther 2017; 46:1026-1027. [PMID: 29052855 DOI: 10.1111/apt.14359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- A Feathers
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - A Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - A N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, New York, NY, USA
| | - L Falzon
- Columbia University Medical Center, New York, NY, USA
| | - S Li Ferry
- Teachers College, Columbia University, New York, NY, USA
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20
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Swaminath A, Feathers A, Ananthakrishnan A, Falzon L, Ferry SL. Systematic review with meta-analysis: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease. Aliment Pharmacol Ther 2017; 46:645-656. [PMID: 28815649 PMCID: PMC5798240 DOI: 10.1111/apt.14253] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 03/30/2017] [Accepted: 07/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite potential adverse-events in a paediatric population, corticosteroids are used to induce remission in paediatric Crohn's disease. Exclusive enteral nutrition also induces remission, but is infrequently used in the USA because corticosteroids are considered the superior therapy. New data have become available since the publication of the most recent meta-analysis in 2007. AIM To see if current literature supports the use of EEN versus CS in paediatric populations. METHODS All studies with comparator arms of exclusive enteral nutrition and an exclusive corticosteroids, with remission clearly defined were identified by searching eight online databases. RESULTS Of 2795 identified sources, nine studies met our inclusion criteria. Eight of these (n = 451), had data that could be abstracted into our meta-analysis. Exclusive enteral nutrition was as effective as corticosteroids in inducing remission (OR = 1.26 [95% CI 0.77, 2.05]) in paediatric Crohn's disease. There was no difference between Exclusive enteral nutrition and corticosteroids efficacy when comparing newly diagnosed Crohn's (OR = 1.61 [95% CI .87, 2.98]) or relapsed (OR = 0.76 [95% CI .29-1.98]). Intestinal healing was significantly more likely among patients receiving Exclusive enteral nutrition compared to corticosteroids (OR = 4.5 [95% CI 1.64, 12.32]). There was no difference in the frequency of biomarker normalisation including CRP (OR = 0.85 [95% CI .44, 1.67]) and faecal calprotectin (OR 2.79 [95% CI .79-10.90]). CONCLUSIONS There is no difference in efficacy between exclusive enteral nutrition and corticosteroids in induction of remission in Crohn's disease in a paediatric population. Exploratory analyses suggest that a greater proportion of patients treated with exclusive enteral nutrition achieved mucosal healing.
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Affiliation(s)
- Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY,
USA
| | | | | | - Louise Falzon
- Columbia University Medical Center, New York, NY, USA
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21
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Kugathasan S, Denson LA, Hyams JS. Exclusive and partial enteral nutrition for Crohn's disease - Authors' reply. Lancet 2017; 390:1486-1487. [PMID: 28952446 DOI: 10.1016/s0140-6736(17)32157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 07/26/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
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Ishige T, Tomomasa T, Tajiri H, Yoden A. Japanese physicians' attitudes towards enteral nutrition treatment for pediatric patients with Crohn's disease: a questionnaire survey. Intest Res 2017; 15:345-351. [PMID: 28670231 PMCID: PMC5478759 DOI: 10.5217/ir.2017.15.3.345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 11/22/2016] [Accepted: 12/01/2016] [Indexed: 01/04/2023] Open
Abstract
Background/Aims Enteral nutrition (EN) is recommended for the treatment of pediatric Crohn's disease (CD) in Japan. However, the indications and treatment protocols for EN vary among hospitals. In the present study, we aimed to determine how EN was administered to pediatric patients and whether physicians followed treatment guidelines in their practices. Methods Two types of questionnaires were administered to 32 physicians who were involved in the treatment of pediatric CD. The consensus questionnaire evaluated the physicians' attitudes towards EN, whereas the efficacy questionnaire collected data on patients with CD, aged <17 years, who had undergone induction therapy between 2006 and 2011. Results A total of 23 physicians responded to the questionnaires. The results of the consensus questionnaire indicated that 82% and 59% of study participants recommended EN treatment for all newly diagnosed pediatric patients with CD and all relapsed patients, respectively. Exclusive EN (EEN) and elemental formula were recommended by 84% and 85% of physicians, respectively. The efficacy questionnaire revealed that 57 of the 58 patients received EN. Elemental formula was used in 39 of 40 patients who were treated with EEN. Of these 40 patients, 27 were treated with EEN alone; of these, 22 (81%) achieved remission without any other treatment. The mean duration of EEN was 15.9 days. Conclusions EN is widely recommended by physicians treating pediatric CD in Japan. In contrast to Western countries, clinicians used elemental formula more often and with a shorter EEN treatment duration.
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Affiliation(s)
- Takashi Ishige
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Hitoshi Tajiri
- Department of Pediatrics, Osaka General Medical Center, Osaka, Japan
| | - Atsushi Yoden
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
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MacLellan A, Moore-Connors J, Grant S, Cahill L, Langille MGI, Van Limbergen J. The Impact of Exclusive Enteral Nutrition (EEN) on the Gut Microbiome in Crohn's Disease: A Review. Nutrients 2017; 9:nu9050447. [PMID: 28468301 PMCID: PMC5452177 DOI: 10.3390/nu9050447] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/18/2017] [Accepted: 04/26/2017] [Indexed: 12/17/2022] Open
Abstract
Crohn’s disease (CD), a form of inflammatory bowel disease (IBD), is thought to arise from a complex interaction of genetics, the gut microbiome, and environmental factors, such as diet. There is clear evidence that dietary intervention is successful in the treatment of CD—exclusive enteral nutrition (EEN) is able to induce remission in up to 80% of CD patients. While the mechanism of action of EEN is not clear, EEN is known to cause profound changes in the gut microbiome. Understanding how EEN modifies the gut microbiome to induce remission could provide insight into CD etiopathogenesis and aid the development of microbiome-targeted interventions to guide ongoing dietary therapy to sustain remission. This review includes current literature on changes in composition and function of the gut microbiome associated with EEN treatment in CD patients.
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Affiliation(s)
- Amber MacLellan
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
| | - Jessica Moore-Connors
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Shannan Grant
- Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Nova Scotia, Canada.
| | - Leah Cahill
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
| | - Morgan G I Langille
- Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Johan Van Limbergen
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
- Department of Immunology & Microbiology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Characteristics of Pediatric Crohn's Disease in Saudi Children: A Multicenter National Study. Gastroenterol Res Pract 2015; 2016:7403129. [PMID: 26858752 PMCID: PMC4709618 DOI: 10.1155/2016/7403129] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/14/2015] [Accepted: 11/02/2015] [Indexed: 12/17/2022] Open
Abstract
Background and Aims. Crohn's disease (CD) is an evolving disease in KSA. Little is known about its characteristics in the Saudi population. The aims of this study were to describe the characteristics of Saudi children with CD and to determine whether the characteristics of CD in KSA are different from those seen in Western countries. Methods. In this study, children younger than eighteen years of age diagnosed with CD between January 2003 and December 2012 were included. Results. Of 330 patients identified, 186 (56.4%) were males. The median age at diagnosis was 15.8 years. A positive family history for IBD in first-degree relatives occurred in 13.6% of patients. The most common symptoms were abdominal pain (84.2%), weight loss (75.2%), and diarrhea (71.8%). The main disease location was ileocolonic (42.1%) and the main disease behavior was nonstricturing and nonpenetrating (63.6%). Perianal involvement was seen in 60 (18.2%) patients. Laboratory findings revealed anemia in 57.9% of patients, low albumin in 34.5%, and high CRP in 39.4%. Conclusions. Saudi children with CD have lower frequency of first-degree relatives with IBD, lower prevalence of early onset disease, longer diagnostic delay, higher prevalence of growth failure, and greater frequency of stricturing and penetrating disease behavior compared to Western patients.
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Toward enteral nutrition for the treatment of pediatric Crohn disease in Canada: a workshop to identify barriers and enablers. Can J Gastroenterol Hepatol 2015; 29:351-6. [PMID: 26076398 PMCID: PMC4610644 DOI: 10.1155/2015/509497] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dietary management of pediatric CD. Workshop participants ranked the exclusivity of enteral nutrition; the health care resources; and cost implications as the top three barriers to its use. Conversely, key enablers mentioned included: standardization and sharing of protocols for use of enteral nutrition; ensuring sufficient dietetic resources; and reducing the cost of EEN to the family (including advocacy for reimbursement by provincial ministries of health and private insurance companies). Herein, the authors report on the discussions during this workshop and list strategies to enhance the use of EEN as a treatment option in the treatment of pediatric CD in Canada.
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Cheng SX, Lightfoot YL, Yang T, Zadeh M, Tang L, Sahay B, Wang GP, Owen JL, Mohamadzadeh M. Epithelial CaSR deficiency alters intestinal integrity and promotes proinflammatory immune responses. FEBS Lett 2014; 588:4158-66. [PMID: 24842610 PMCID: PMC4234694 DOI: 10.1016/j.febslet.2014.05.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/30/2014] [Accepted: 05/02/2014] [Indexed: 12/22/2022]
Abstract
The intestinal epithelium is equipped with sensing receptor mechanisms that interact with luminal microorganisms and nutrients to regulate barrier function and gut immune responses, thereby maintaining intestinal homeostasis. Herein, we clarify the role of the extracellular calcium-sensing receptor (CaSR) using intestinal epithelium-specific Casr(-/-) mice. Epithelial CaSR deficiency diminished intestinal barrier function, altered microbiota composition, and skewed immune responses towards proinflammatory. Consequently, Casr(-/-) mice were significantly more prone to chemically induced intestinal inflammation resulting in colitis. Accordingly, CaSR represents a potential therapeutic target for autoinflammatory disorders, including inflammatory bowel diseases.
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Affiliation(s)
- Sam X Cheng
- Division of Gastroenterology, Department of Pediatrics, University of Florida, Gainesville, FL 32607, USA
| | - Yaíma L Lightfoot
- Department of Infectious Diseases and Pathology, University of Florida, Gainesville, FL 32608, USA; Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Tao Yang
- Department of Infectious Diseases and Pathology, University of Florida, Gainesville, FL 32608, USA; Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mojgan Zadeh
- Department of Infectious Diseases and Pathology, University of Florida, Gainesville, FL 32608, USA; Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Lieqi Tang
- Division of Gastroenterology, Department of Pediatrics, University of Florida, Gainesville, FL 32607, USA
| | - Bikash Sahay
- Department of Infectious Diseases and Pathology, University of Florida, Gainesville, FL 32608, USA; Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Gary P Wang
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jennifer L Owen
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mansour Mohamadzadeh
- Department of Infectious Diseases and Pathology, University of Florida, Gainesville, FL 32608, USA; Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA.
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Enteral nutrition in Crohn's disease: an underused therapy. Gastroenterol Res Pract 2013; 2013:482108. [PMID: 24382954 PMCID: PMC3870077 DOI: 10.1155/2013/482108] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/08/2013] [Accepted: 11/08/2013] [Indexed: 12/13/2022] Open
Abstract
This paper reviews the literature on the history, efficacy, and putative mechanism of action of enteral nutrition for inflammatory bowel disease in both paediatric and adult patients. It also analyses the reasoning behind the low popularity of exclusive enteral nutrition in clinical practice despite the benefits and safety profile.
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Day AS, Burgess L. Exclusive enteral nutrition and induction of remission of active Crohn's disease in children. Expert Rev Clin Immunol 2013; 9:375-83; quiz 384. [PMID: 23557272 DOI: 10.1586/eci.13.12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Exclusive enteral nutrition is an effective therapy for the management of active Crohn's disease, especially in children and adolescents. This therapeutic approach involves the use of a liquid nutritional product with the exclusion of normal diet for a period of many weeks. Although recent studies have helped to delineate some aspects of how exclusive enteral nutrition should be used, there remain many gaps in our understanding. In addition, several recent reports have provided intriguing insights into the mechanisms of this nutritional approach.
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Affiliation(s)
- Andrew S Day
- Department of Paediatrics, University of Otago (Christchurch), Christchurch Hospital, Christchurch, New Zealand.
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The epidemiology of anemia in pediatric inflammatory bowel disease: prevalence and associated factors at diagnosis and follow-up and the impact of exclusive enteral nutrition. Inflamm Bowel Dis 2013; 19:2411-22. [PMID: 23899546 DOI: 10.1097/mib.0b013e31829ed855] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Anemia is poorly studied in pediatric inflammatory bowel disease. This study explored the epidemiology and associated factors of anemia at diagnosis, after 1 year, and during treatment with exclusive enteral nutrition (EEN). METHODS Three cohorts were included: (1) a representative population of newly diagnosed inflammatory bowel disease children (n = 184); (2) patients currently receiving care with data available at diagnosis (n = 179) and after 1 year (n = 139); and (3) 84 children treated with EEN. RESULTS At diagnosis, 72% were anemic. Abnormal inflammatory markers were more common in Crohn's disease with severe anemia (severe versus no anemia [%]: raised C-reactive protein; 89% versus 48%; suboptimal albumin; 97% versus 29%; P < 0.002). Anemic children with Crohn's disease had shorter diagnosis delay and lower BMI than nonanemic patients (severe versus mild versus no anemia, median [interquartile range]; diagnosis delay [months]: 3 [3.9] versus 6 [10] versus 8 [18], P < 0.001; BMI z score [SD]: -1.4 [1.4] versus -1.3 [1.5] versus -0.2 [1.4], P = 0.003). Extensive colitis was associated with severe anemia in ulcerative colitis. The proportion of severely anemic patients decreased from 34% to 9% and mild anemia doubled at 1 year. After EEN, severe anemia decreased (32% to 9%; P < 0.001) and the hemoglobin concentration increased by 0.75 g/dL. This was observed only after 8 weeks of treatment. Disease improvement and low hemoglobin at EEN initiation but not weight gain were associated with hemoglobin improvement. CONCLUSIONS Anemia is high at diagnosis and follow-up and should receive more attention from the clinical team; however, the focus should remain suppression of inflammatory process in active disease.
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Chronisch-entzündliche Darmerkrankungen (CED). PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498796 DOI: 10.1007/978-3-642-24710-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gerasimidis K, Talwar D, Duncan A, Moyes P, Buchanan E, Hassan K, O'Reilly D, McGrogan P, Edwards CA. Impact of exclusive enteral nutrition on body composition and circulating micronutrients in plasma and erythrocytes of children with active Crohn's disease. Inflamm Bowel Dis 2012; 18:1672-81. [PMID: 22069243 DOI: 10.1002/ibd.21916] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 09/14/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutritional therapy is the primary treatment for active pediatric Crohn's disease (CD) in the UK/Europe, improving disease activity and anthropometry. This study assessed changes in micronutrient status during exclusive enteral nutrition (EEN). METHODS Seventeen children (male/female: 8/9; median age: 12.7 years) with active CD were treated exclusively for 6-8 weeks on a polymeric feed (Modulen IBD; Nestle, UK). Body impedance was measured at baseline, during EEN, and posttreatment on normal diet and converted to z-scores of fat and lean mass. Blood samples for nutrient analysis were collected from 13 children at baseline, end of EEN, and posttreatment. RESULTS Lean but not fat mass improved at the end of EEN (initiation vs. end of EEN; fat mass [z-score]: -0.5 vs. -0.3; P = 0.141; lean mass [z-score]: -2.1 vs. -0.8; P < 0.0001). At baseline several children presented with suboptimal concentrations of carotenoids, trace elements, vitamin C, B6, and folate in plasma but not in erythrocytes. EEN improved concentrations for several nutrients, but more than 90% of patients had depleted concentrations of all carotenoids. The latter improved on normal diet but other micronutrients, which improved during EEN, returned toward pretreatment concentrations. CONCLUSIONS Lean but not fat mass improved at the end of EEN. Median concentrations for several plasma micronutrients improved on EEN but carotenoids were depleted. These findings may have implications for clinical practice and producers of enteral feeds. As plasma concentrations for many micronutrients can be affected by the acute phase response, measurements in erythrocytes may be a better marker of actual body stores.
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Affiliation(s)
- Konstantinos Gerasimidis
- Lifecourse Nutrition and Health, School of Medicine, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Royal Hospital for Sick Children, Glasgow, UK.
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Alhagamhmad MH, Day AS, Lemberg DA, Leach ST. An update of the role of nutritional therapy in the management of Crohn's disease. J Gastroenterol 2012; 47:872-82. [PMID: 22699323 DOI: 10.1007/s00535-012-0617-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 05/14/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is an increasingly global health concern. Currently without a cure, it significantly alters the quality of life of Crohn's disease sufferers and places a heavy financial burden on the community. Recent reports show that the rising prevalence of Crohn's disease is no longer confined to Western countries, with considerable increases seen particularly in Asia. Nutritional problems are often associated with Crohn's disease, most notably in the paediatric population, with underweight and stunting commonly seen at presentation. In addition, linear growth retardation and pubertal delay can also manifest in these younger patients. Therefore, exclusive enteral nutrition has been used as a therapeutic option to treat Crohn's disease, in part to address the nutritional complications of the disease. Exclusive enteral nutrition can improve nutrition as well as induce remission at a rate equivalent to corticosteroids. It is safe particularly with long-term use and can induce mucosal healing, considered the gold standard for therapy, at a rate superior to corticosteroids. Exclusive enteral nutrition has thus become the preferred therapeutic option in many centres for the treatment of paediatric Crohn's disease. This review discusses the role of exclusive enteral nutrition as a therapeutic option for the treatment of Crohn's disease, as well as the latest findings into its mechanisms of action.
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Affiliation(s)
- Moftah H Alhagamhmad
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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Whitten KE, Rogers P, Ooi CKY, Day AS. International survey of enteral nutrition protocols used in children with Crohn's disease. J Dig Dis 2012; 13:107-12. [PMID: 22257479 DOI: 10.1111/j.1751-2980.2011.00558.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Differing protocols have been utilized in published studies evaluating exclusive enteral nutrition (EEN) in the management of active pediatric Crohn's disease. This study aimed to ascertain the protocols currently utilized in different pediatric centers around the world and to highlight their similarities and differences. METHODS A questionnaire was circulated to individuals at pediatric centers in countries in Europe, North America and Asia-Pacific. Respondents were asked to indicate the number of children treated with EEN at their centers in the previous years and to provide details of their protocol used for administering EEN to these children. RESULTS Responses were received from 35 separate centers (42% of those asked). The duration of EEN varied from <6 weeks to >12 weeks, but was most commonly 6 to 8 weeks. Although 23 different formulas were utilized across the centers, most (90%) used polymeric formulas. Flavourings were commonly added to formulas but wide variations existed between centers with the prescription of food and fluids permitted during the EEN period. The reintroduction of food after EEN also varied greatly: the most common recommendations were for an initial low-fiber diet (26%) or the gradual introduction of food quantity as the formula volume decreased (52%). CONCLUSIONS This questionnaire-based study has shown the wide variations in EEN protocols used in different areas of the world. The development of consistent protocols may enhance the acceptance, efficacy and wider utilization of this therapy.
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Affiliation(s)
- Kylie E Whitten
- Departments of Nutrition and Dietetics Gastroenterology, Sydney Children's Hospital School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease. J Pediatr Gastroenterol Nutr 2012; 54:298-305. [PMID: 22002478 DOI: 10.1097/mpg.0b013e318235b397] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Exclusive enteral nutrition is an effective yet often underused therapy for the induction of remission in pediatric Crohn disease. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition formed the Enteral Nutrition Working Group to review the use of enteral nutrition therapy in pediatric Crohn disease. The group was composed of 5 pediatric gastroenterologists and 1 pediatric nutritionist, all with an interest and/or expertise in exclusive enteral nutrition. Specific attention was placed upon review of the evidence for efficacy of therapy, assessment of the variations in care, identification of barriers to its widespread use, and compilation of the necessary components for a successful program. The present guideline is intended to aid physicians in developing an enteral nutrition therapy program and potentially promote its use.
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Abstract
Many foods have been implicated in theories about the etiology of inflammatory bowel disease. While evidence has accumulated that nutritional factors as part of overall lifestyle changes may play a role in the growing incidence, no specific dietary recommendations except the promotion of breastfeeding can currently be given to decrease the risk of developing Crohn's disease or ulcerative colitis. For the treatment of Crohn's disease in children and adolescents, however, enteral feeding with a semi-elemental diet seems to be as effective as corticosteroids in inducing and maintaining remission. In the meta-analyses, advantages of one formula over the other are evened out, and more research is warranted into the anti-inflammatory properties of different nutrients, such as polyunsaturated fatty acids, butyrate, glutamine, and cytokines, such as transforming growth factors-beta. Unfortunately, for practical reasons, nutritional therapy remains underutilized, even though pediatric patients are most vulnerable to the harmful effects of nutrient deficiencies on growth, pubertal development, and bone health. There is hope that in the future the new field of nutrigenomics may enable physicians to more accurately tailor a specific diet to the patient genotype.
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Affiliation(s)
- Dietmar Scholz
- Department of Pediatrics, Justus-Liebig-University, Giessen, Germany
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Gråfors JM, Casswall TH. Exclusive enteral nutrition in the treatment of children with Crohn's disease in Sweden: a questionnaire survey. Acta Paediatr 2011; 100:1018-22. [PMID: 21272070 DOI: 10.1111/j.1651-2227.2011.02178.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM The general use of exclusive enteral nutrition (EEN) as therapy for children with Crohn's disease (CD) in Sweden has not previously been studied. Thus, the aim of this study was to investigate how EEN is used as therapy in Sweden for children with CD. METHODS A questionnaire was sent to all 37 paediatric units in Sweden that treat children with inflammatory bowel disease. RESULTS The response rate was 78%, which covers nearly 90% of Sweden's paediatric population between 0 and 17 years of age. Ninety-six per cent of the units used EEN as a treatment option for children with CD, and 65% of the units used EEN as their primary therapy in newly diagnosed CD. The standard duration of EEN was 6 weeks, but the questionnaire revealed a span of 4-8 weeks. The use of polymeric formula was just as common as a combination of polymeric and elemental formulas. Fifty-seven per cent used oral nutrition supplements, and 81% allowed some extent of concomitant feeding, the addition of food and fluids, during EEN. All units used enteral nutrition to some extent as maintenance therapy after EEN was discontinued. CONCLUSIONS In Sweden, EEN is used as therapy for children with Crohn's disease (CD), but the EEN protocols vary as to choice of formula and type of food and fluids allowed during EEN. Standardized EEN protocols would enable multicentre studies in Sweden, with the objective of investigating how EEN treatment can be improved and employed in the most efficient way.
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Affiliation(s)
- Josefin M Gråfors
- Department of Clinical Nutrition and Dietetics, Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
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Physician attitudes and practices of enteral nutrition as primary treatment of paediatric Crohn disease in North America. J Pediatr Gastroenterol Nutr 2011; 52:38-42. [PMID: 20975582 DOI: 10.1097/mpg.0b013e3181e2c724] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of exclusive enteral nutrition (EEN) in children with Crohn disease has not been universally adopted by North American paediatric gastroenterologists. This is in stark contrast to their European counterparts. The present study aimed to define attitudes and practice patterns of EEN use by members of the North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition. METHODS Members were contacted by e-mail and provided with access to a Web-based survey. RESULTS Surveys were completed by 326 of 1162 (30.7%) eligible North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition members from North America (86% United States, 14% Canada). Thirty-one percent of respondents reported never using EEN, 55% reported sparse use, and 12% reported regular use. Physicians in Canada reported significantly more use than those in United States (P < 0.001). Currently working and previously working in a centre where EEN was used were highly correlated with both the perceived appropriateness of EEN and the regularity of its use (P < 0.01). More American physicians than Canadian physicians reported that concurrent medical therapy was necessary to induce remission (P < 0.001). Canadian respondents were more likely to use maintenance therapy than American respondents (P = 0.02). Compliance issues were seen as the main disadvantages of EEN and as the major barrier to increased use by nonregular users. CONCLUSIONS There are significant variations in the patterns of use and the acceptance of EEN between Canada and the United States, with Canadian physicians showing a greater use of EEN. The use of EEN appears influenced by the extent to which physicians are exposed to its use both in their training and in their current practice setting.
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Pozler O, Chládek J, Malý J, Hroch M, Dědek P, Beránek M, Krásničanová P. Steady-state of azathioprine during initiation treatment of pediatric inflammatory bowel disease. J Crohns Colitis 2010; 4:623-8. [PMID: 21122571 DOI: 10.1016/j.crohns.2010.06.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 06/20/2010] [Accepted: 06/21/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Azathioprine (AZA) has a slow onset of action in treatment of pediatric inflammatory bowel disease (IBD). It is anticipated, that this delay correlates to the kinetics of 6-thioguanine nucleotides (6-TGN) accumulation. The aim of this study was to evaluate the time to steady state of 6-TGN concentration in red blood cells. METHODS The inclusion criteria were: a) age 0-19 years b) IBD diagnosis c) AZA treatment initiation. High performance liquid chromatography was used for the 6-TGN analysis. Concentrations of metabolites were studied in weeks 0, 1, 2, 5, and 8 after beginning of treatment. RESULTS The inclusion criteria were matched to 18 patients with IBD. The median time to steady state of 6-TGN was 55.3 days. The mean 6-TGN concentration at the steady state achieved 326 (SD 154) pmol/8.108 erythrocytes. High erythrocyte TPMT activity corresponds to the low steady state 6-TGN concentration and vice versa. This correlation reached statistical significance (p<0.01) for the dose expressed in mg per square meter of body surface area. CONCLUSION The time to steady state of 6-TGN erythrocyte concentration is significantly shorter than would expected according to clinical observation describe earlier.
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Affiliation(s)
- O Pozler
- Dept. of Pediatrics, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Czech Republic.
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Samson F, Cagnard B, Leray E, Guggenbuhl P, Bridoux-Henno L, Dabadie A. Longitudinal study of bone mineral density in children after a diagnosis of Crohn's disease. ACTA ACUST UNITED AC 2010; 34:554-61. [PMID: 20739132 DOI: 10.1016/j.gcb.2010.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Revised: 01/15/2010] [Accepted: 01/31/2010] [Indexed: 02/07/2023]
Abstract
AIM The purpose of this study was to measure the bone mineral density (BMD) of children with Crohn's disease (CD) and to prospectively assess its evolution. PATIENTS AND METHODS A total of 27 children (20 boys, seven girls), aged 12.1±2.5 years, were recruited at the time of CD diagnosis. Dual-energy X-ray absorptiometry (DEXA) was used to measure BMD, expressed as Z scores for chronological age (BMD/CA) and bone age (BMD/BA). One year later, BMD was measured again to identify any correlations with disease activity [group A (active disease) vs group R (remission)]. RESULTS BMD/CA and BMD/BA were negatively correlated with delay in diagnosis (P<0.0001 and P<0.05, respectively). BMD/CA was less than -2 standard deviation (SD) in nine patients and BMD/BA was less -2 SD in four patients. At the follow-up, the increase in BMD was smaller in group A (n=14), whether expressed as absolute values (-0.002 vs 0.040 g/cm(2) per year; P<0.024) or as percentages (-0.2 vs 6.6%; P<0.041); changes in BMD/CA (-0.5 vs -0.1 SD/year) and BMD/BA (-0.3 vs 0 SD/year) did not differ. CONCLUSION Diagnostic delay greatly affects BMD in children with CD even prior to corticosteroid therapy. The risk of low BMD increases with persistent CD activity, although the risk is reduced in association with bone maturation delay.
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Affiliation(s)
- F Samson
- Département de médecine de l'enfant et de l'adolescent, hôpital Sud, 16 boulevard de Bulgarie, Rennes cedex 2, France
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Otley AR, Russell RK, Day AS. Nutritional therapy for the treatment of pediatric Crohn's disease. Expert Rev Clin Immunol 2010; 6:667-676. [PMID: 20594139 DOI: 10.1586/eci.10.37] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Crohn's disease and ulcerative colitis are lifelong conditions with particular effects upon nutrition, especially in children and adolescents. Various therapies are available for these conditions but there remains no cure. Over the last decades, exclusive enteral nutrition (EEN) has been demonstrated to have efficacy in the induction of remission, along with numerous other nutritional and inflammatory benefits. This article reviews the benefits and outcomes associated with EEN in Crohn's disease. The potential mechanisms of this therapy are highlighted, along with factors that are barriers to the wider use of EEN.
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Affiliation(s)
- Anthony R Otley
- Department of Gastroenterology, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Levine A, Kori M, Dinari G, Broide E, Shaoul R, Yerushalmi B, On A, Bujanover Y, Pröls M, Greinwald R. Comparison of two dosing methods for induction of response and remission with oral budesonide in active pediatric Crohn's disease: a randomized placebo-controlled trial. Inflamm Bowel Dis 2009; 15:1055-61. [PMID: 19229988 DOI: 10.1002/ibd.20881] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Oral budesonide has been found to be comparable to systemic corticosteroids in mild to moderately active Crohn's disease (CD). Remission rates in pediatric studies to date have been suboptimal (47%-55%), even though patients with colonic involvement were excluded in some studies. In addition, the optimal pediatric dosing regimen has never been evaluated before. METHODS This was a randomized, controlled, double-blind study in 70 children with mild or moderately active CD randomized to 1 of 2 groups: Group 1: Standard dose budesonide (9 mg/day) for 7 weeks followed by 6 mg budesonide daily for an additional 3 weeks. Group 2: Induction with 12 mg/day for the first month followed by the same regimen as Group 1. Outcome measures included a decrease in Pediatric Crohn's Disease Activity Index and remission rates. Patients with colonic disease were not excluded. RESULTS At week 7 a clinical response was obtained in 51.4% in Group 1 versus 74.3% in Group 2. A significant decrease in C-reactive protein was seen only in Group 2. At the end of treatment, remission was obtained in 42.9% in Group 1 versus 65.7% in Group 2 (P = 0.054). There was no significant difference in adverse events or serum cortisol. CONCLUSIONS Use of an induction dose of budesonide followed by a budesonide taper resulted in a trend to higher rates of clinical remission and a decrease in inflammation, without an increase in steroid-associated side effects. Budesonide was also useful for patients with ileocolonic disease.
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Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology Unit, Wolfson Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Day AS, Stephenson T, Stewart M, Otley AR. Exclusive enteral nutrition for children with Crohn's disease: use in Australia and attitudes of Australian paediatric gastroenterologists. J Paediatr Child Health 2009; 45:337-41. [PMID: 19490411 DOI: 10.1111/j.1440-1754.2009.01498.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM Although available data support a role for exclusive enteral nutrition (EEN) in children with Crohn's disease (CD), use of this therapy varies. The aim of this study was to define the patterns of use of EEN across Australia and to better understand the reasons for this variation. METHODS Using an existing email network, Australian paediatric gastroenterologists were asked to provide details of their attitudes towards, and use of, EEN in children. A questionnaire was designed to direct responses, with regard to use of EEN, to current EEN protocols and patterns of use. RESULTS Twenty-one replies were received (58% response). Although 12 respondents felt that EEN was an appropriate therapy for CD, only 8 regularly used EEN for their patients. Usage varied between states and within units. Current use was related to practitioners' experiences of EEN during their gastroenterology training. The concerns of those who did not recommend EEN included compliance, cost and resource demands. The doctors who recommend EEN reported that family support, team approach and disease location were important factors for a positive outcome from EEN. Current protocols varied in terms of type of formula, length of therapy and use of concurrent medications. CONCLUSIONS Variations in care were illustrated across these paediatric gastroenterologists. Practitioners have many reasons and concerns about the use of EEN: these impede the wider use of EEN for paediatric CD. More consistent protocols for the use of EEN and an improved understanding of the mechanisms of EEN could lead to enhanced use of this therapy.
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Affiliation(s)
- Andrew S Day
- School of Women's and Children's Health, University of New South Wales, Canada.
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Is exclusive enteral nutrition enough for children with Crohn's disease? Proc Nutr Soc 2008. [DOI: 10.1017/s002966510800013x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Day AS, Whitten KE, Sidler M, Lemberg DA. Systematic review: nutritional therapy in paediatric Crohn's disease. Aliment Pharmacol Ther 2008; 27:293-307. [PMID: 18045244 DOI: 10.1111/j.1365-2036.2007.03578.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND At least 25% of individuals diagnosed with Crohn's disease (CD) have onset of disease in childhood. Almost all children with CD have nutritional impairments, such as weight loss or stunting, at diagnosis or subsequently. Nutritional therapy (exclusive enteral nutrition) is established as a valid and effective treatment in paediatric CD. The advantages of this approach are induction of remission and control of inflammatory changes, mucosal healing, positive benefits to growth and overall nutritional status, and avoidance of other medical therapies. AIM To provide a comprehensive up-to-date review of the roles of nutritional therapy in CD and of the data supporting this therapy. METHODS A search of PubMed was performed with search terms 'enteral nutrition', 'nutritional therapy', 'Crohn disease' and 'children'. Relevant articles were selected from this search. In addition, the reference lists of available articles were reviewed for further relevant articles. RESULTS Nutritional therapy offers numerous benefits in the management of CD. Recent work has begun to elucidate the likely mechanisms of this therapy. These include direct mucosal anti-inflammatory effects and alteration of intestinal microflora. CONCLUSION Further studies are required to define longer-term effects of nutritional therapy in patients with CD.
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Affiliation(s)
- A S Day
- Department of Gastroenterology, Sydney Children's Hospital, Sydney, Australia.
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Gerasimidis K, McGrogan P, Hassan K, Edwards CA. Dietary modifications, nutritional supplements and alternative medicine in paediatric patients with inflammatory bowel disease. Aliment Pharmacol Ther 2008; 27:155-65. [PMID: 17944995 DOI: 10.1111/j.1365-2036.2007.03552.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Data on use of complementary and alternative medicine in children with inflammatory bowel disease are scarce. AIM To assess prevalence, predictors and parental attitude to the use of complementary and alternative medicine in a paediatric population with inflammatory bowel disease in the west of Scotland. METHODS Questionnaire survey encompassing alternative therapists, nutritional supplements and dietary modifications used in the management of inflammatory bowel disease was used. Demographics, disease and treatment data were also collected. RESULTS 86 guardians completed the survey. 61% had used at least one type and 37% were using complementary and alternative medicine recently. The most common types were probiotics (44%) and dairy-free diet (28%). Higher parental education and young parental age were predictors of complementary and alternative medicine use. An increased number of oral steroid courses and prior use of complementary and alternative medicine for other health reasons were associated with use of alternative therapists. Personal recommendation and to complement conventional medicine were the main reasons for using complementary and alternative medicine. 48% judged complementary and alternative medicine at least partially effective. 86% agreed that doctors should be supportive of use. 89% would give complementary and alternative medicine to their children. CONCLUSIONS Use of complementary and alternative medicine was higher in children with IBD than in adults with the same disease. The gastrointestinal nature of the disease could explain the high use of nutritional supplements and dietary modifications in this survey.
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Affiliation(s)
- K Gerasimidis
- Human Nutrition Section, Division of Developmental Medicine, University of Glasgow, Yorkhill Hospitals, Glasgow, UK
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Rosh JR, Gross T, Mamula P, Griffiths A, Hyams J. Hepatosplenic T-cell lymphoma in adolescents and young adults with Crohn's disease: a cautionary tale? Inflamm Bowel Dis 2007; 13:1024-30. [PMID: 17480018 DOI: 10.1002/ibd.20169] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Therapy for the inflammatory bowel diseases increasingly includes the use of immune-modifying and biologic therapies. Recently, in young patients with IBD, an association has been noted between the use of infliximab along with concomitant purine analogues and the development of hepatosplenic T-cell lymphoma (HSTCL)-a rare and all but incurable form of non-Hodgkin's lymphoma. This report briefly reviews the issue of lymphoma and IBD therapy. Additionally, a description of HSTCL and a summary of the known cases of this apparent therapeutic complication are presented. Clinical options in light of this new information are explored.
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Affiliation(s)
- Joel R Rosh
- Goryeb Children's Hospital/Atlantic Health, Morristown, New Jersey, USA.
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Abstract
Crohn's disease is a common indication for referral to pediatric gastroenterology. While most patients with Crohn's disease respond to standard induction therapy, steroid-refractory or steroid-dependent disease is a frequently encountered problem. This review discusses the data existing in both the adult and pediatric literature for medical therapy of refractory pediatric Crohn's disease.
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Affiliation(s)
- William A Faubion
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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Jaspers GJ, Verkade HJ, Escher JC, de Ridder L, Taminiau JAJM, Rings EHHM. Azathioprine maintains first remission in newly diagnosed pediatric Crohn's disease. Inflamm Bowel Dis 2006; 12:831-6. [PMID: 16954801 DOI: 10.1097/01.mib.0000232470.00703.67] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
6-Mercaptopurine (6-MP) maintains remission in pediatric Crohn's disease (CD). Azathioprine, a prodrug of 6-MP, is used for maintenance of remission of CD in Europe. We evaluated to what extent azathioprine is used in newly diagnosed pediatric CD patients and whether maintenance of remission differed between patients using azathioprine or not. Charts of children (diagnosed 1998-2003, follow-up > or = 18 mo) were reviewed. Active disease was defined as Pediatric Crohn's Disease Activity Index (PCDAI) greater than 10 or systemic corticosteroid use. Remission was defined as PCDAI 10 or less without use of corticosteroids. Eighty-eight children (55M/33F, age 12 +/- 3 yr) were included. Seventy-two (82%) patients received azathioprine during the follow-up period (38 +/- 17 mo). Patients diagnosed after 2000 received azathioprine significantly earlier during the course of disease compared with those diagnosed earlier (median, at 233 vs. 686 days; P < 0.05). At initial presentation, moderate-severe disease activity and prescription of corticosteroids were more prevalent in patients using azathioprine compared with nonazathioprine patients (75% vs. 52%; P < 0.05; and 89% vs. 58%; P < 0.005, respectively). Duration of corticosteroid use was longer in patients receiving azathioprine (232 vs. 168 days; P < 0.005). Median maintenance of first remission in patients who initially used corticosteroids, however, was longer in patients receiving azathioprine compared with nonazathioprine patients (PCDAI, 544 vs. 254 days, P = 0.08; corticosteroid free, 575 vs. 259 days, P < 0.05, respectively). We conclude that, since 2000, azathioprine is being introduced earlier in the treatment of newly diagnosed pediatric CD patients. The use of azathioprine is associated with prolonged maintenance of the first remission.
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Affiliation(s)
- Gerald J Jaspers
- Pediatric Gastroenterology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abstract
PURPOSE OF REVIEW Treatment algorithms for inflammatory bowel disease are changing rapidly. Increased and earlier use of immunomodulatory drugs and availability of biologic agents have reduced dependence on corticosteroids and made mucosal healing a realistic goal. It is timely to debate the role of enteral nutrition in this evolving therapeutic armamentarium for Crohn's disease, and to examine the mechanisms of its anti-inflammatory effects in light of current understanding of disease pathogenesis. RECENT FINDINGS Clinical studies have suggested that response to enteral nutrition is associated with decreased mucosal inflammation in Crohn's disease, that isolated Crohn's colitis is less responsive and that exclusive enteral nutrition is required. Basic research has demonstrated that lipids in the intestinal lumen can alter signalling of the mucosal immune system by intestinal epithelial cells. Exclusive enteral nutrition is associated with alteration of enteric microflora. SUMMARY Enteral nutrition is an efficacious treatment of active inflammation involving the ileum; recent-onset disease may be particularly responsive. The significance of effects on enteric flora deserves further exploration in view of the importance of microbes to disease pathogenesis.
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Affiliation(s)
- Anne M Griffiths
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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