Plasma prednisolone levels after administration of prednisolone-21-phosphate as a retention enema in colitis

Systematic review: the adverse effects of sodium phosphate enema

BACKGROUND

Sodium-phosphate enemas are widely used to treat constipation, and are rarely associated with side effects.

AIM

A systematic review of the literature was conducted to identify the most common adverse effects of sodium-phosphate enemas and associated risk factors.

METHODS

A systematic search was conducted in Internet (MEDLINE), and the Cochrane Library, from January 1957 to March 2007.

RESULTS

A total of 761 references were identified initially, and 39 relevant papers were finally selected. The most common therapeutic indications included constipation (63%). Sixty-eight per cent of the patients having adverse effects had associated conditions, the most common being gastrointestinal motility disorders, cardiological diseases and renal failure. Virtually, all side effects were due to water and electrolyte disturbances. Most patients were under 18 years of age (66%) or older than 65 years (25%). A total of 12 deaths were found.

CONCLUSION

The main side effects caused by sodium phosphate enemas are water and electrolyte disturbances. The main risk factors are extreme age and associated comorbidity.

The short-term effects of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) on bone formation and bone mineral density in acute ulcerative colitis

BACKGROUND

The aetiology of bone loss in ulcerative colitis is multifactorial, but corticosteroid treatment is an important risk factor. A novel formulation of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) has been developed, in order to deliver high mucosal levels of prednisolone within the colon but with little systemic absorption. The aim of this study was to investigate its efficacy, and short-term effects on bone formation and bone mineral density.

METHODS

In a 12-week longitudinal study 13 patients with active colitis were treated with a reducing dose of Predocol. Disease activity scores were recorded and the bone formation marker osteocalcin was measured before, during and after treatment, with hip and spine bone mineral density assessed at baseline and after treatment.

RESULTS

Eleven of the 13 patients completed the study. Compared with baseline, disease activity scores improved significantly after 4 weeks [difference in means, 6.9; 95% confidence interval (CI), 5.2, 8.7; P < 0.0001] and 12 weeks (difference in means, 5.7; 95% CI, 3.3, 8.2; P < 0.0001) of treatment. Osteocalcin did not fall compared with baseline [16.91 mg/l (95% CI, 12.70, 21.12)], after 4 weeks [13.67 mg/l (95% CI, 8.72, 18.60)] (difference in means, 3.25; 95% CI, 2.37, 8.87; P = 0.23) or 12 weeks [23.91 mg/l (95% CI, 16.10, 31.74)] (difference in means, 13.23; 95% CI, 2.45, 16.48; P = 0.13) of treatment. Similarly, bone mineral density at the hip [0.99 g/cm (95% CI, 0.90, 1.09)] did not change after 12 weeks of treatment [1.00 g/cm (95% CI, 0.89, 1.11)] (difference in means, 0.01; 95% CI, 0.25, 0.34; P = 0.74). Spine bone mineral density did not fall from pre-treatment levels [1.20 g/cm (95% CI, 1.11, 1.30)] after 12 weeks [1.19 g/cm (95% CI, 1.10, 1.29)] (difference in means, 0.01; 95% CI, 0.004, 0.01; P = 0.26).

CONCLUSIONS

These results confirm that Predocol is effective treatment for acute ulcerative colitis and short courses of the steroid have no adverse effects on bone formation and bone mineral density. The encouraging results from this study suggest that Predocol may be a significant advance in preventing corticosteroid induced bone loss in ulcerative colitis.

Treatment of inflammatory bowel disease with corticosteroids

Corticosteroids are a mainstay in the treatment of inflammatory bowel disease. Administered topically, orally, or intravenously corticosteroids rapidly and consistently improve moderate to severe active ulcerative colitis and Crohn's disease, although they are ineffective in the maintenance of remission in either illness. The beneficial effects of corticosteroid therapy are counterbalanced by their many side effects. A better understanding of the mechanism of steroid action and toxicity has led to the development of novel corticosteroids that offer the promise of continued efficacy with minimal toxicity. This article reviews the role of conventional and novel corticosteroids in the management of inflammatory bowel disease.

Review article: issues in oral administration of locally acting glucocorticosteroids for treatment of inflammatory bowel disease

Inflammatory bowel diseases are treated in some cases by local administration of anti-inflammatory drugs. Local delivery of drugs in the colon following oral administration may lead to improved efficacy/side-effect profiles and may improve patient compliance. This review covers a number of issues important in the design of oral delivery systems of glucocorticosteroids for local therapy of colonic inflammation. The choice of specific glucocorticosteroids is based on the drug's physicochemical and pharmacological properties. The conditions under which an orally administered glucocorticosteroid (or other drug) must be delivered to treat ulcerative colitis are also discussed. These conditions include variations in local pH, transit throughout the gastrointestinal tract, the potential role of gut microflora, and drug dissolution in both the healthy and diseased large intestine. The effective delivery of topically-active glucocorticosteroids in ulcerative colitis and Crohn's colitis patients is complex, but if successful could improve their usefulness.

The effect of rectally administered steroids on bone turnover: a comparative study

BACKGROUND

Oral glucocorticoids contribute significantly to the risk of osteoporosis in patients with inflammatory bowel disease. Less well established are the effects of rectally administered steroids on bone metabolism.

AIM

To investigate the effects of two widely used rectal foam preparations (prednisolone metasulphobenzoate and hydrocortisone acetate) on biochemical markers of bone turnover.

METHODS

Twenty-four patients with active inflammatory bowel disease randomly received a standard course of either prednisolone metasulphobenzoate or hydrocortisone acetate for 2 weeks. Biochemical markers of bone turnover were measured before, during and after treatment. Bone formation markers measured were serum osteocalcin (BGP) and bone-specific alkaline phosphatase (BALP). Urinary deoxypyridinoline (DPD) was measured to assess bone resorption.

RESULTS

Disease activity scores improved during treatment (difference in mean Powell-Tuck score = 3.4, 95% CI: 2.0-4.8, P < 0.0001) and were similar in both hydrocortisone and prednisolone-treated groups. There was no significant reduction in BALP or BGP during treatment with either steroid preparation, and urinary DPD did not change significantly during treatment.

CONCLUSIONS

During a 2-week course of rectal hydrocortisone acetate or prednisolone metasulphobenzoate, there was no significant change in biochemical markers of bone formation or resorption. These results suggest that pharmacological doses of rectal steroid foam preparations do not significantly impair bone turnover in patients with inflammatory bowel disease.

Rectal corticosteroids versus alternative treatments in ulcerative colitis: a meta-analysis

BACKGROUND

Clear strategies to optimise the use of corticosteroids in ulcerative colitis are lacking.

AIM

A meta-analysis was undertaken to examine critically the role of rectal corticosteroids in the management of active distal ulcerative colitis.

METHODS

All reported randomised controlled trials were retrieved by searching the Medline and EMBASE databases and the bibliographies of relevant studies. Trials which met inclusion criteria were assessed for scientific rigour. Data were extracted by two independent observers according to predetermined criteria.

RESULTS

Of 83 trials retrieved, 33 met inclusion criteria. Pooled odds ratios (POR) showed conventional rectal corticosteroids and rectal budesonide to be clearly superior to placebo. In seven trials, rectal 5-aminosalicylic acid (5-ASA) was significantly better than conventional rectal corticosteroids for inducing remission of symptoms, endoscopy, and histology with POR of 2.42 (95% confidence interval (CI) 1.72-3.41), 1.89 (95% CI 1.29-2.76), and 2.03 (95% CI 1.28-3.20), respectively. Rectal budesonide was of comparable efficacy to conventional corticosteroids but produced less endogenous cortisol suppression. Side effects, although inconsistently reported, were generally minor. A cost comparison of rectal preparations showed 5-ASA to be less expensive than corticosteroids.

CONCLUSIONS

Rectal 5-ASA is superior to rectal corticosteroids in the management of distal ulcerative colitis.

Safety of corticosteroids and immunosuppressive agents in ulcerative colitis

For many years, corticosteroids have been the mainstay for treating acute ulcerative colitis. In patients with refractory disease, immunosuppressive therapy may be indicated, including azathioprine or its metabolite 6-mercaptopurine, cyclosporin and possibly methotrexate. Their benefits in ulcerative colitis must be weighed up against their possible adverse effects, the availability of surgical cure for this condition, and the long-term risk of carcinoma complicating colitis that applies in patients with chronic extensive disease. Information about the safety of corticosteroids and immunosuppressive agents has accumulated as a result of their extensive use in inflammatory bowel disease, organ transplantation and various other disorders.

Rectal steroids suppress bone formation in patients with colitis

BACKGROUND

The aetiology of bone loss in inflammatory bowel disease is multifactorial, but oral corticosteroids are an important contributory factor. Rectally administered steroids are widely used in patients with distal disease, but very little is known about their effect on bone metabolism. The aim of this study was to investigate the effect of a standard course of rectal prednisolone on biochemical markers of bone turnover.

METHODS

In a longitudinal study of 10 patients, biochemical markers of bone turnover were measured before, during and after treatment with prednisolone metasulphobenzoate (Predfoam, Pharmax Ltd) 20 mg twice daily for 2 weeks. Bone formation markers measured were serum osteocalcin (BGP), bone-specific alkaline phosphatase (BALP) and procollagen carboxy-terminal propeptide (PICP). Urinary deoxypyridinoline (dPyr) was measured to assess bone resorption.

RESULTS

Disease activity scores improved during treatment (difference in mean Powell-Tuck score = 2.3 (+/-13.1), 95% CI: 0.11-4.48, P = 0.04). There was a significant fall in BALP (P = 0.02) during treatment, and a rapid but non-significant fall in BGP (P = 0.19). PICP (0.42), and urinary dPyr (0.30) did not change significantly during treatment.

CONCLUSIONS

Following a standard 2-week course of rectal prednisolone metasulphobenzoate, we observed a significant fall in bone-specific alkaline phosphatase activity. These results suggest that bone formation is suppressed in patients with distal colitis treated with pharmacological doses of rectal steroids.

Comparison of budesonide and 5-aminosalicylic acid enemas in active distal ulcerative colitis

BACKGROUND

Budesonide is a new corticosteroid with high topical anti-inflammatory activity but little systemic effect. The aim of the present study was to compare the efficacy and safety of budesonide enema (2 mg/100 mL) and 5-ASA enema (mesalazine 1 g/100 mL) given for 4 weeks in the treatment of active distal ulcerative colitis and proctitis.

METHODS

Ninety-seven patients were studied in a multicentre single-blind randomized group-comparative trial. The primary efficacy variables were endoscopy and histopathology scores obtained at 0, 2 and 4 weeks. Clinical symptoms were the secondary efficacy variables. Haematology, chemistry and adverse events were the safety variables.

RESULTS

Budesonide and 5-ASA enemas both resulted in a significant improvement in endoscopy and histopathology scores but no difference could be demonstrated between the two treatment groups. There was also a significant improvement of symptoms (number of bowel movements per day, quality of stools, presence of blood and mucus, and state of well-being) within both groups but no difference between the two treatment groups. The clinical remission rate at 4 weeks was, however, 38% for patients treated with budesonide enema but 60% for those treated with 5-ASA enema (P = 0.03). No adverse events attributed to the study drugs were recorded in either of the groups.

CONCLUSIONS

Budesonide enema 2 mg/100 mL appears to be as efficient and well-tolerated as 5-ASA enema in the treatment of active distal ulcerative colitis and proctitis.

Prednisolone metasulphobenzoate foam retention enemas suppress the hypothalamo-pituitary-adrenal axis

BACKGROUND

Corticosteroid enemas represent effective treatment for ulcerative proctitis, but absorption into the systemic circulation may have undesirable metabolic consequences. Prednisolone metasulphobenzoate, a lipophobic corticosteroid derivative, is designed to be absorbed poorly through the recto-sigmoid mucosa, but the effects of foam enema preparations upon the hypothalamo-pituitary-adrenal axis have not been examined.

METHODS

Nine patients suffering from active ulcerative proctitis underwent four weeks of therapy with prednisolone metasulphobenzoate foam enemas. The hypothalamo-pituitary-adrenal axis, defined using the modified single-dose metyrapone test, glucose homeostasis and lipid profiles were studied before and after treatment.

RESULTS

The hypothalamo-pituitary-adrenal axis was significantly depressed after the treatment period; mean stimulated plasma cortisol concentration fell from 384 +/- 244 (s.d.) to 288 +/- 252 nmol/L, P < 0.02; stimulated mean plasma 11-deoxycortisol concentration fell from 677 +/- 333 to 407 +/- 326 nmol/L, P < 0.01. Mean fasting plasma glucose, insulin, C-peptide, fructosamine and triglyceride concentration were unchanged, whilst the mean serum cholesterol concentrations rose from 5.6 +/- 1.1 to 6.0 +/- 1.2 mmol/L (not significant).

CONCLUSION

Prednisolone metasulphobenzoate foam enemas have significant systemic and endocrine metabolic effects, which could assume importance with long-term therapy.

Comparison of bismuth citrate and 5-aminosalicylic acid enemas in distal ulcerative colitis: a controlled trial

An enema that contained a complex of bismuth citrate and polyacrylate was compared with 5-aminosalicylic acid (5-ASA) enemas for treatment of distal ulcerative colitis. The multicentre trial involving 63 patients was randomised and double blind with enemas given over four weeks; clinical, sigmoidoscopic, and histological assessments were made. Improvements were seen in both treatment groups. Clinical remission was seen in 18 of 32 patients treated with 5-ASA and 12 of 31 patients treated with bismuth citrate-carbomer (chi 2 1.94; p = 0.16). Sigmoidoscopic remission occurred in 20 of 32 patients in the 5-ASA group and 15 of 31 patients given bismuth (chi 2 1.27; p = 0.26). Improvement of rectal biopsy histology by at least one grade was seen in 16 of 32 patients in the 5-ASA group and 14 of 31 patients with bismuth (chi 2 0.15; p = 0.70). Analysis of covariance gave no significant difference between groups, although there was a trend favouring 5-ASA. There was no evidence of bismuth accumulation during the trial. Bismuth enemas may offer a new therapeutic option in distal ulcerative colitis.

Current management of inflammatory bowel disease

The aetiology of ulcerative colitis and Crohn's disease remains unknown. While this remains so, treatment must be directed towards pathogenetic mechanisms. Corticosteroids, sulphasalazine and the new salicylates, the immunosuppressants azathioprine, 6-MP and, more recently, cyclosporin and metronidazole have become the accepted and standard forms of treatment. The importance of maintaining nutritional status is often overlooked but must be considered in every patient. Recognition of the occurrence of disease in all age groups, and in particular in children and adolescents, is also important, as is an appreciation of the special problems involved. The possibility of surgery at some stage of the disease should be raised with the patient. As the pathogenetic mechanisms of inflammatory bowel disease are further elucidated, new forms of treatment will be developed. This is already happening, with studies looking at such agents as immunoglobulin G, eicosapentaenoic acid and a new specific inhibitor of 5-lipoxygenase. These offer hope of more potent drugs with low side-effect profiles that may complement or replace the currently available agents used in the management of inflammatory bowel disease.

Double blind, controlled trial of 4-aminosalicylic acid and prednisolone enemas in distal ulcerative colitis

Corticosteroid or 5-aminosalicylic acid enemas are the treatment of choice for distal ulcerative colitis but up to one third of patients may be unresponsive. As an alternative therapy might be advantageous, the efficacy of six weeks' treatment with 2 g 4-aminosalicylic acid (4-ASA) (n = 24) and 20 mg prednisolone enemas (n = 21) were compared in a double blind, randomised trial in patients with acute distal (less than 30 cm from the anus) ulcerative colitis. Baseline demography and clinical severity were similar in both groups. Five of 24 patients receiving 4-ASA and 4 of 21 receiving prednisolone did not complete the trial because of deteriorating symptoms, failure to improve, or side effects. At the time of leaving the trial, 24 hour stool frequency, the presence of blood in the stools, and histological and sigmoidoscopic appearances were similar in both groups. Symptomatic improvement occurred in 17 of 24 patients receiving 4-ASA compared with 11 of 21 receiving prednisolone (chi 2 = 1.62, NS). Complete symptomatic improvement occurred in 9 of 24 patients receiving 4-ASA compared with 5 of 21 receiving prednisolone (chi 2 = 0.98, NS). Histological improvement was seen in 9 of 24 patients on 4-ASA compared with 7 of 21 on prednisolone (chi 2 = 0.08, NS). One patient receiving 4-ASA was considered to have an idiosyncratic reaction to the drug but other side effects were not considered to be drug related. Thus, 4-ASA, previously used in the treatment of tuberculosis (para-aminosalicyclic acid), is as good as prednisolone in the treatment of distal ulcerative colitis and should be considered in patients unresponsive to steroids or in whom steroid treatment is undesirable.

Medical management of severe inflammatory disease of the rectum and distal colon: non-nutritional aspects

Rectal bleeding is the cardinal symptom in patients with inflammation of the rectum, and initial management must be directed at establishing an underlying diagnosis. In many patients in the Western World this will be idiopathic inflammatory bowel disease, although in all cases other causes such as infection must be excluded. Idiopathic proctitis is usually due to either ulcerative colitis or Crohn's disease, and in both conditions corticosteroids, either systemic or topical, provide the mainstay of treatment. The 5-aminosalicylic acid drugs are helpful in both acute and maintenance treatment, again given either systemically or topically, while metronidazole is of value in patients with Crohn's disease. In those with refractory proctitis alternative agents such as azathioprine, immunomodulating drugs and barrier agents may be useful. Severe inflammation of the rectum secondary to pelvic irradiation will also usually respond to topical steroid therapy, although sucralfate enemas may be equally successful; in resistant cases other treatments may be needed. Infective proctitis, when diagnosed, may require treatment with specific antimicrobial agents.

Budesonide enema in distal ulcerative colitis. A randomized dose-response trial with prednisolone enema as positive control. The Danish Budesonide Study Group

The effect of budesonide, 1, 2, and 4 mg/100 ml in daily enemas, on active distal ulcerative colitis was compared with that of prednisolone disodium phosphate enemas, 25 mg/100 ml, in a multicentre, randomized, group-comparative trial. A total of 146 patients with active disease were treated for 2 weeks. Data from 139 were valid for statistical analyses. Bowel habits, proctoscopy findings, and histologic pictures were evaluated, and plasma cortisol was determined for measurement of influence on the hypothalamic-pituitary-adrenal axis. Clinical symptoms and proctoscopy findings improved within all treatment groups. The improvement of these effect variables tended to be less after treatment with the lowest dose of budesonide, 1 mg/100 ml, than after the other treatments. Plasma cortisol did not change in any of the budesonide groups, whereas a mean reduction of 30% (P = 0.07) was observed after prednisolone. It can be concluded that budesonide enemas of 2 mg/100 ml constitute an attractive alternative to prednisolone enemas for topical treatment of distal ulcerative colitis.

Inflammatory bowel disease

An increasing number of options are available for the treatment of inflammatory bowel disease; the selection depends on the extent and severity of the disease. Experience with sulfasalazine and corticosteroids has led to a proliferation of 5-aminosalicylic acid (5-ASA) compounds and experimentation with alternative corticosteroid preparations. Given rectally 5-ASA is particularly effective in the treatment of distal ulcerative colitis, and experience is accumulating with several oral formulations. Metronidazole is useful in some cases, and immunosuppressive agents have a role in some patients with chronic refractory disease. A variety of measures, such as nutritional therapy, surgery and psychosocial support, are important elements of therapy. Further therapeutic innovations are expected as the etiology and pathogenesis are clarified.

Treatment of distal ulcerative colitis with beclomethasone enemas: high therapeutic efficacy without endocrine side effects. A prospective, randomized, double-blind trial

Sixteen patients with 18 attacks of distal ulcerative colitis were treated randomly with either 0.5 mg topically administered beclomethasone dipropionate (BDP) or 5 mg betamethasone phosphate (BMT). The effect of the steroid enemas on adrenocortical function was examined by ACTH tests, which were performed before and 20 days after treatment. At completion of the trial, a marked suppression of the adrenocortical function was found in seven of eight patients treated for nine attacks with BMT but not in any patients in the BDP group (P less than 0.01). The mean posttreatment basal and stimulated plasma cortisol levels in the BMT group were significantly lower as compared with the BDP group. The overall therapeutic response assessed by score systems was comparable in the two treatment groups. It is concluded that, in the topical treatment of ulcerative colitis, BDP is preferable to BMT because it exerts an equal anti-inflammatory action without affecting adrenocortical function.

Blood eosinophilia and ulcerative colitis--influence of ethnic origin

Blood eosinophilia is an alleged manifestation of ulcerative colitis. To investigate this association and to determine the effect of race, the occurrence of eosinophilia in all 44 Asians presenting between 1968-84 was compared to that in an age- and sex-matched group of indigenous white Caucasian patients presenting over the same period. Nineteen (43%) of the Asians presented with an eosinophilia compared to only 3 Caucasians (P less than 0.0001); similar numbers (14 and 13) in both groups demonstrating transient eosinophilia on occasions during maintenance treatment although not related to clinical relapse. A control group of Asians with other disorders not known to be associated with eosinophilia did not manifest this abnormality on presentation although 3 patients did so transiently during out-patient observation. Eosinophilia is a feature of ulcerative colitis in many Asians possibly due either to an unusual racial response to ulcerative colitis or as a reflection of the underlying pathogenesis of their disease. We have not confirmed earlier suggestions of such a feature in white Caucasians. Eosinophilia occurring during maintenance treatment in both groups may be drug-related.

Therapeutic benefits from a poorly absorbed prednisolone enema in distal colitis

A double blind controlled trial has been conducted in 40 patients to compare the therapeutic effects of prednisolone metasulphobenzoate enemas with those of prednisolone-21-phosphate enemas. Both enemas brought about improvement in symptoms and sigmoidoscopic appearances in more than 70% of patients treated. The absorption of prednisolone from the metasulphobenzoate enema in three patients was less than from the 21-phosphate enema. In view of the low plasma prednisolone concentrations obtained, there are theoretical advantages in using a poorly absorbed enema to avoid the possibility of systemic steroid effects in patients requiring long term steroid treatment.

Topical administration of 5-aminosalicylic acid enemas in patients with ulcerative colitis. Studies on rectal absorption and excretion

5-aminosalicylic acid (5-ASA) is a new treatment for patients suffering from ulcerative colitis but only limited information is available about its rectal absorption. We therefore studied seven patients with ulcerative colitis in remission, and five with active disease to determine acetylated and free 5-ASA plasma concentrations and urinary acetyl 5-ASA after the administration of three different types of enemas: (2 g 5-ASA/100 ml, 4 g/100 ml, and 200 ml). In patients in remission urinary acetyl 5-ASA excretion was dose and volume dependent (p less than 0.01; p less than 0.05) but this correlation was absent in active disease. Because aminosalicylates are usually eliminated through the kidney, these low values (10% in active disease and 19% in those in remission) suggest that the beneficial action may be local. Urinary recovery was significantly lower in patients with active disease (p less than 0.01; p less than 0.02). No accumulation of 5-ASA was found in plasma after repeated daily administration.

A comparison of prednisolone enemas with low-dose oral prednisolone in the treatment of acute distal ulcerative colitis

The therapeutic efficacy of prednisolone metasulphobenzoate enemas in the treatment of distal colitis has been compared with that of low-dose oral prednisolone, in a single-blind, cross-over trial. Treatment with steroid enemas resulted in symptomatic and sigmoidoscopic evidence of improvement more frequently than treatment with a dosage of oral steroid calculated to achieve similar plasma prednisolone levels. In addition to demonstrating, for the first time, that prednisolone metasulphobenzoate enemas are effective in the treatment of colitis, this study suggests that their efficacy is due to a local action rather than systemic absorption.

Drug therapy of inflammatory bowel disease

Although the etiology of inflammatory bowel disease is unknown and specific therapy is unavailable, enough information on existing empiric agents is available to allow rational therapy. These agents include sulfasalazine, steroids, immunosuppressive drugs, metronidazole and cholestyramine. Sulfasalazine is a two-part molecule that depends on bacterial cleavage in the colon to deliver locally acting 5-aminosalicylate, whose mechanism of action may relate to inhibition of prostaglandin synthesis. The other half of the molecule, sulfapyridine, is responsible for most of the side effects of the drug. While the efficacy of sulfasalazine in the treatment and prevention of attacks of ulcerative colitis is well established, its use in Crohn's disease appears to be limited to patients with active colitis and ileo-colitis. Sulfasalazine is of major benefit in preventing relapses in patients with ulcerative colitis in remission. New formulations of 5-aminosalicylate may allow delivery of the apparently active moiety to the small bowel and colon without concomitant sulfapyridine toxicity. Corticosteroids are highly effective in acute attacks of ulcerative colitis and Crohn's ileitis and ileo-colitis; the mechanism of antiinflammatory action remains speculative. However, maintenance therapy with steroids is ineffective in preventing relapses or recurrent attacks of either ulcerative colitis or Crohn's disease. Steroid enemas allow topical administration to patients with distal colitis and proctitis with few systemic side effects. In children with growth failure associated with active Crohn's disease, amelioration by steroid therapy may actually restore normal growth. Immunosuppressive agents such as azathioprine and 6-mercaptopurine are of little value in active Crohn's disease when administered alone; however, in combination with other agents they may help diminish steroid dose, close fistulae and prevent relapse. Their mode of action likely depends on long-term cytostatic effects on immune effector cells. Concern for leukopenia and the development of late malignancy has limited their use to patients not responding to other therapies. Metronidazole, an antimicrobial agent that is effective against anaerobes, has recently been shown useful in Crohn's disease involving the colon and perianal area. Its mechanism of action is uncertain, but may be related to its antibacterial actions on anaerobes. Cholestyramine can be successfully used to control bile salt-induced diarrhea in Crohn's patients with terminal ileal resections. Effective drug therapy of inflammatory bowel disease is only part of a total program of management including reassurance, frequent explanation, well-timed use of surgery, and an understanding physician.

Inhibition of leucocyte motility by drugs used in ulcerative colitis

The effects on leucocyte motility of sulphasalazine (Salazopyrin) and its metabolites sulphapyridine and 5 amino-salicylic acid have been compared with those of prednisolone and indomethacin. Sulphasalazine, its active metabolite 5 amino-salicylic acid, and prednisolone are all potent inhibitors of leucocyte motility. Sulphapyridine and indomethacin are non-inhibitory. Inhibition of leucocyte motility may explain why sulphasalazine and 5 amino-salicylic acid are effective in ulcerative colitis while sulphapyridine is not. The lack of effect of indomethacin suggests that this action of sulphasalazine does not involve inhibition of prostaglandin synthesis.

Treatment of distal ulcerative colitis (proctosigmoiditis) in relapse: comparison of hydrocortisone enemas and rectal hydrocortisone foam

Thirty patients with distal colitis (proctosigmoiditis) in relapse were randonly allocated to twice daily treatment with traditional aqueous hydrocotrisone enemas (Cortenemas) or a suspension of hydrocortisone in an inert foam base (Colifoam). Each treatment contained the same amount of hydrocortisone. Clinical, sigmoidoscopic, and histological response was assessed after two weeks. Both agents were effective, and broadly similar in terms of objective improvement, but subjective improvement was greater with the foam preparation, and several patients expressed a preference to this mode of treatment.

Rectally administered prednisolone--evidence for a predominantly local action

Plasma prednisolone levels have been compared in healthy volunteers and in patients suffering from idiopathic proctocolitis after the administration of standard retention enemata containing either prednisolone-21-phosphate or prednisolone metasulphobenzoate sodium. The levels were significantly lower after the latter, irrespective of the presence or degree of activity of the disease. Prednisolone metasulphobenzoate appeared to be as effective as the 21-phosphate ester for the treatment of proctocolitis in the few patients where the two drugs were compared. It seems possible that the beneficial effect of the form of therapy is exerted predominantly locally, rather than by systemic action.

Plasma prednisolone levels and adrenocortical responsiveness after administration of prednisolone-21-phosphate as a retention enema

Plasma prednisolone levels have been measured by radioimmunoassay after oral and rectal administration to healthy volunteers and to patients with idiopathic proctocolitis. The amount of prednisolone absorbed from a 20 mg retention enema given to patients with proctocolitis was about 44% of that absorbed from the same dose orally administered. Adrenocortical response to synthetic ACTH in patients receiving prolonged rectal therapy was either normal, or only slightly impaired, and this may be related to the pattern of steroid absorption rather than to the total amount absorbed.

Primary suture of the perineal wound following rectal excision for inflammatory bowel disease

Delay in healing of the perineal wound is a major cause of disability in patients after excision of the rectum. The outcome of primary suture in 76 patients treated at St Mark's Hospital between 1967 and 1976 was correlated with a number of factors describing the patients, their preparation for surgery and details of surgical technique and management. The perineal wound healed by first intention in 33 patients. The remaining 43 patients regarded as failures included 7 with delayed breakdown after initial healing. The results showed that women fared better than men. Excision of the rectum following colectomy and ileostomy was associated with failure of the perineal wound to heal in 9 out of 10 patients. Treatments with peroperative ampicillin and topical antibacterial agents were both correlated significantly with success. Preoperative sepsis and operative contamination were followed by perineal sepsis and wound breakdown on 16 out of 21 occasions. Discriminant analysis showed that topical and peroperative antibacterial treatments, sex, preoperative sepsis and finally ACTH were the most important variables in descending order of importance. The prediction of success and failure by this procedure was 72.4 per cent correct.

Plasma prednisolone concentrations: comparison of radioimmunoassay and competitive protein binding assay

A comparison was made between plasma concentrations of prednisolone measured by both competitive protein binding radioassay (CPB) and radioimmunoassay (RIA) and, with each assay, using a calibration curve generated from individual subject data and from pooling the individual calibration curva data. The plasma samples were obtained from six normal adult male volunteers who were pretreated with dexamethasone to suppress endogenous hydrocortisone and who then ingested 10 mg of prednisolone. Both the standard curve data and the plasma concentrations were evaluated statistically. It was shown that the CPB method has considerably greater precision than the RIA method and could be employed in bioavailability and pharmacokinetic studies of both prednisolone and prednisone. It was also shown that corticosteroid binding globulin cross-reacts considerably less with the major metabolite of prednisolone, 20beta-dihydroprednisolone, than the particular antiserum used in the RIA.