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Chatzidaki V, Wood R, Alegakis A, Lawson M, Fagbemi A. Parenteral support and micronutrient deficiencies in children with short bowel syndrome: A comprehensive retrospective study. Clin Nutr ESPEN 2023; 58:270-276. [PMID: 38057017 DOI: 10.1016/j.clnesp.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND & AIMS Short bowel syndrome (SBS) is the leading cause of chronic intestinal failure. The duration of parenteral support (PS) and the long-term micronutrient needs in children with SBS vary, based on their clinical and anatomical characteristics. Our study aimed to review the clinical course and identify high risk patient groups for prolonged PS and long-term micronutrient supplementation. METHODS A retrospective review was conducted on electronic medical records of children with SBS and chronic intestinal failure who were enrolled in the multidisciplinary intestinal rehabilitation program at Manchester Children's Hospital, UK. Children were included in the review if they required PN for more than 60 days out of 74 consecutive days and had at least 3 years of follow-up. Statistical analysis was performed using IBM SPSS Statistics 24.0. RESULTS 40 children with SBS achieved enteral autonomy (EA) and 14 remained dependent on PS after 36 months of follow up. Necrotizing enterocolitis was the most common cause for intestinal resection (38.9%) followed by gastroschisis (22.2%), malrotation with volvulus (20.4%), segmental volvulus (9.3%) and long segment Hirschsprung disease (1.9%). Those who achieved EA had significantly longer intestinal length 27.5% (15.0-39.3) than those who remained on PS 6.0% (1.5-12.5) (p < 0.001). Type I SBS was only found in the PS cohort. Median PN dependence was 10.82 months [IQR 5.73-20.78]. Congenital diagnosis was associated with longer PN dependence (21.0 ± 20.0) than acquired (8.7 ± 7.8 months), (p = 0.02). The need for micronutrient supplementation was assessed after the transition to EA; 87.5% children had at least one micronutrient depletion, most commonly Vitamin D (64.1%), followed by iron (48.7%), Vitamin B12 (34.2%), and vitamin E (28.6%). Iron deficiency and vitamin A depletion were correlated with longer PS after multivariate analysis (OR: 1.103, 1.006-1.210, p = 0.037 and OR: 1.048, 0.998-1.102, p = 0.062 respectively). CONCLUSION In our cohort, small bowel length was the main predictor for EA. Children on longer PS, had more often a congenital cause of resection and were at risk for micronutrient deficiencies in EA.
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Affiliation(s)
- V Chatzidaki
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK.
| | - R Wood
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Alegakis
- Laboratory of Toxicology, University of Crete, Greece
| | - M Lawson
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Fagbemi
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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3
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The Role of a Colon-in-Continuity in Short Bowel Syndrome. Nutrients 2023; 15:nu15030628. [PMID: 36771335 PMCID: PMC9918966 DOI: 10.3390/nu15030628] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/11/2023] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare gastrointestinal condition that is defined as having less than 200 cm of remaining small intestine. SBS results from extensive surgical resection and is associated with a high risk for intestinal failure (IF) with a need for parenteral support (PS). Depending on the region of intestinal resection, three different main anatomy types can be distinguished from each other. In this review, we synthesize the current knowledge on the role of the colon in the setting of SBS-IF with a colon-in-continuity (SBS-IF-CiC), e.g., by enhancing the degree of intestinal adaptation, energy salvage, and the role of the microbiota. In addition, the effect of the disease-modifying treatment with glucagon-like peptide-2 (GLP-2) analogs in SBS-IF-CiC and how it differs from patients without a colon will be discussed. Overall, the findings explained in this review highlight the importance of preservation of the colon in SBS-IF.
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Naimi RM, Hvistendahl MK, Poulsen SS, Kissow H, Pedersen J, Nerup NA, Ambrus R, Achiam MP, Svendsen LB, Jeppesen PB. Effects of glepaglutide, a long-acting glucagon-like peptide-2 analog, on intestinal morphology and perfusion in patients with short bowel syndrome: Findings from a randomized phase 2 trial. JPEN J Parenter Enteral Nutr 2023; 47:140-150. [PMID: 35511704 PMCID: PMC10084040 DOI: 10.1002/jpen.2389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/18/2022] [Accepted: 05/02/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The proadaptive effects of glucagon-like peptide-2 (GLP-2) include stimulation of intestinal mucosal growth as well as intestinal blood flow and angiogenesis. We have recently reported that daily subcutaneous injections of glepaglutide, a long-acting GLP-2 analog, improved intestinal absorptive function in patients with short bowel syndrome (SBS). As secondary and exploratory end points, the effects of glepaglutide on intestinal morphology and perfusion are reported. METHODS The following assessments were done in 18 patients with SBS in a randomized, crossover, dose-finding, phase 2 trial before and after three weeks of treatment with glepaglutide: plasma citrulline and mucosa biopsies to assess changes in (1) intestinal morphology by immunohistochemistry and (2) gene expressions associated with absorption, proliferation, and markers of tight-junction integrity by quantitative polymerase chain reaction. Intestinal perfusion was assessed in stoma nipples by laser speckle contrast imaging and quantitative fluorescence angiography with indocyanine green. RESULTS In the 1- and 10-mg dose groups, glepaglutide significantly increased plasma citrulline by 15.3 µmol/L (P = 0.001) and 15.6 µmol/L (P = 0.001), respectively. Trends toward an increase in villus height, crypt depth, and epithelium height were seen in the same groups. No significant changes were seen in gene expressions or intestinal perfusion. CONCLUSION The increase in plasma citrulline and the morphological improvements may partly account for improvement in the intestinal absorptive function. However, the finding of a stability in perfusion after three weeks of treatment with glepaglutide may have been preceded by a more profound acute-phase increase in intestinal perfusion at treatment initiation.
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Affiliation(s)
- Rahim M Naimi
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Mark K Hvistendahl
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Steen S Poulsen
- Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Hannelouise Kissow
- NNF Center of Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Pedersen
- NNF Center of Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj A Nerup
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Rikard Ambrus
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Lars B Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Palle B Jeppesen
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen, Denmark
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5
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Jeppesen PB, Shahraz S, Hopkins T, Worsfold A, Genestin E. Impact of intestinal failure and parenteral support on adult patients with short-bowel syndrome: A multinational, non-interventional, cross-sectional survey. JPEN J Parenter Enteral Nutr 2022; 46:1650-1659. [PMID: 35289416 PMCID: PMC9543571 DOI: 10.1002/jpen.2372] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/22/2022]
Abstract
Background Patients with short‐bowel syndrome and intestinal failure (SBS‐IF) require parenteral support (PS) and experience various symptoms and comorbidities. This survey assessed the impact of SBS‐IF and PS on patients and their health‐related quality of life (HRQoL). Methods An online survey of adult patients who had a self‐reported clinician diagnosis of SBS‐IF and were receiving PS was conducted in France, Germany, Italy, the UK, and the USA. Patients reported symptoms, comorbidities, and treatment satisfaction; the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI:SHP) and the Home Parenteral Nutrition‐Quality of Life (HPN‐QoL) questionnaire assessed impact on work and HRQoL, respectively. Results Patients (N = 181; aged 52.0 ± 15.1 years; 56.9% women) experienced fatigue (75.1%), anemia (49.7%), and difficulty spending time with family (36.5%) and friends (30.4%). A total work productivity loss of 37.5% was calculated in patients reporting employment (29.3%). Patients typically (64.0%) reported some degree of satisfaction with their PS treatment. Almost two‐thirds (59.7%) reported that their PS was either “not,” “a little,” or “moderately” convenient. The mean HPN‐QoL scores were higher for patients who were satisfied with treatment (n = 116; 17.1 ± 21.0 [median, 16.7; interquartile range, 0.0–31.7]) than for patients who were dissatisfied/neither (n = 65; 1.7 ± 19.7 [median, 0.0; interquartile range, –13.3–13.3]). Conclusions Patients with SBS‐IF who are receiving PS experience burdensome symptoms and comorbidities and report impacts on work productivity and time spent with friends and family. This study can increase awareness of the impacts of SBS‐IF and PS and how treatment satisfaction may influence patients’ health and HRQoL.
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Affiliation(s)
- Palle B Jeppesen
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Saeid Shahraz
- ICON plc, San Francisco,, California, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA.,Komodo Health, Inc., San Francisco, California, USA
| | - Thomas Hopkins
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
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Bioletto F, D’Eusebio C, Merlo FD, Aimasso U, Ossola M, Pellegrini M, Ponzo V, Chiarotto A, De Francesco A, Ghigo E, Bo S. Efficacy of Teduglutide for Parenteral Support Reduction in Patients with Short Bowel Syndrome: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14040796. [PMID: 35215445 PMCID: PMC8880479 DOI: 10.3390/nu14040796] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 12/13/2022] Open
Abstract
Teduglutide has been described as an effective treatment for parenteral support (PS) reduction in patients with short bowel syndrome (SBS). However, a quantitative summary of the available evidence is still lacking. PubMed/Medline, EMBASE, Cochrane library, OVID, and CINAHL databases were systematically searched up to July 2021 for studies reporting the rate of response (defined as a ≥20% reduction in PS) to teduglutide among PS-dependent adult patients. The rate of weaning (defined as the achievement of PS independence) was also evaluated as a secondary end-point. Ten studies were finally considered in the meta-analysis. Pooled data show a response rate of 64% at 6 months, 77% at 1 year and, 82% at ≥2 years; on the other hand, the weaning rate could be estimated as 11% at 6 months, 17% at 1 year, and 21% at ≥2 years. The presence of colon in continuity reduced the response rate (-17%, 95%CI: (-31%, -3%)), but was associated with a higher weaning rate (+16%, 95%CI: (+6%, +25%)). SBS etiology, on the contrary, was not found to be a significant predictor of these outcomes, although a nonsignificant trend towards both higher response rates (+9%, 95%CI: (-8%, +27%)) and higher weaning rates (+7%, 95%CI: (-14%, +28%)) could be observed in patients with Crohn's disease. This was the first meta-analysis that specifically assessed the efficacy of teduglutide in adult patients with SBS. Our results provide pooled estimates of response and weaning rates over time and identify intestinal anatomy as a significant predictor of these outcomes.
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Affiliation(s)
- Fabio Bioletto
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Chiara D’Eusebio
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Fabio Dario Merlo
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Umberto Aimasso
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Marta Ossola
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Marianna Pellegrini
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Valentina Ponzo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Alessia Chiarotto
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Antonella De Francesco
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Ezio Ghigo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Simona Bo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
- Correspondence: ; Tel.: +39-011-633-6036
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Nordsten CB, Molsted S, Bangsgaard L, Fuglsang KA, Brandt CF, Niemann MJ, Jeppesen PB. High Parenteral Support Volume Is Associated With Reduced Quality of Life Determined by the Short‐Bowel Syndrome Quality of Life Scale in Nonmalignant Intestinal Failure Patients. JPEN J Parenter Enteral Nutr 2020; 45:926-932. [DOI: 10.1002/jpen.1958] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 02/05/2023]
Affiliation(s)
| | - Stig Molsted
- Department of Clinical Research Nordsjaellands Hospital Hilleroed Denmark
| | - Louise Bangsgaard
- Department of Gastroenterology and Hepatology Rigshospitalet Copenhagen Denmark
| | | | | | - Mads J. Niemann
- Department of Anesthesiology The Copenhagen Muscle Research Centre Rigshospitalet Copenhagen Denmark
| | - Palle B. Jeppesen
- Department of Gastroenterology and Hepatology Rigshospitalet Copenhagen Denmark
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Abstract
The ability to provide parenteral support represents a revolutionary change in medical therapy for patients with temporary and inadequate intestinal absorptive capacity or for patients with chronic intestinal failure due to digestive diseases. Nevertheless, due to the rarity of intestinal failure, a de facto policy of "discrimination by organ failure treatment" exists in many countries whereby this problem is under-recognized and under-treated. With the increasing recognition of the pathophysiological consequences of intestinal resection and the occurrence of new pro-adaptive treatments for patients suffering from short bowel syndrome, this review reflects on the history of developments in this area and discusses current practice and future directions of the field.
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Chen K, Mu F, Xie J, Kelkar SS, Olivier C, Signorovitch J, Jeppesen PB. Impact of Teduglutide on Quality of Life Among Patients With Short Bowel Syndrome and Intestinal Failure. JPEN J Parenter Enteral Nutr 2019; 44:119-128. [PMID: 31006876 PMCID: PMC7004164 DOI: 10.1002/jpen.1588] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/22/2019] [Accepted: 03/13/2019] [Indexed: 11/14/2022]
Abstract
Background Teduglutide reduces or eliminates parenteral support (PS) dependency in patients with short bowel syndrome (SBS). Recent post hoc analyses demonstrated that effects are correlated with baseline PS volume. We assessed the SBS‐related quality‐of‐life (QoL) impact of teduglutide, particularly whether improvements are greater among subgroups achieving more PS volume reduction. Methods Using phase 3 trial data of teduglutide in patients with SBS (NCT00798967), change in Short Bowel Syndrome–Quality of Life (SBS‐QoL) scores from baseline were compared between teduglutide vs placebo in the overall population and subgroups classified by baseline PS volume requirement, disease etiology, and bowel anatomy. Generalized estimating equation models were fitted to assess impact of teduglutide on SBS‐related QoL using data from all visits, adjusted for baseline characteristics. Results Of 86 patients, 43 each were randomized to teduglutide or placebo (mean age: 51 vs 50 years, respectively). In adjusted analyses, teduglutide had a nonsignificant reduction (improvement) of −8.6 points (95% CI: 2.6 to −19.8) in SBS‐QoL sum score from baseline to Week‐24 vs placebo. The impact of teduglutide varied by subgroup. Patients treated with teduglutide experienced significantly greater reductions in SBS‐QoL sum score at Week‐24 vs placebo in 2 subgroups, ie, the third (highest) tertile baseline PS volume (−27.3, 95% CI: −50.8 to −3.7) and inflammatory bowel disease (IBD; −29.6, 95% CI: −46.3 to −12.9). Results were similar for SBS‐QoL subscale and item scores. Conclusions The impact of teduglutide treatment on SBS‐related QoL vs placebo varied among subgroups and was significant and most pronounced among patients with highest baseline PS volume requirement or IBD.
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Affiliation(s)
- Kristina Chen
- Shire Human Genetic Therapies, Inc. (a member of the Takeda group of companies), Cambridge, Massachusetts, USA
| | - Fan Mu
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Jipan Xie
- Analysis Group, Inc., Los Angeles, California, USA
| | | | - Clément Olivier
- Shire International GmbH (a member of the Takeda group of companies), Zug, Switzerland
| | | | - Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
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10
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Abstract
Short bowel syndrome (SBS) is the major cause of chronic intestinal failure (IF), defined as 'the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth'. Areas covered: Spontaneous intestinal adaptation, including increased hormonal secretion, development of hyperphagia and gut microbiota dysbiosis, occurs 2 years after resection, improving intestinal absorption and decreasing PN dependency. Hormonal treatments, promoting intestinal hyperadaptation, have been proposed in patients with SBS with chronic IF. Clinical studies showed teduglutide to increase urine production and reduce the need for parenteral support volume in these patients. According to the latest ESPEN Guidelines, if a growth factor treatment is considered, the GPL2 analog, teduglutide, should be the first-choice treatment. Expert opinion: These therapies underline the importance of patient monitoring at home and the complexity for HPN adaptation. A multidisciplinary approach should be a gold standard.
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Affiliation(s)
- Lore Billiauws
- a Department of Gastroenterology and Nutrition Support , APHP Beaujon Hospital , Clichy , France.,b Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies , Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot , Paris , France
| | - Francisca Joly
- a Department of Gastroenterology and Nutrition Support , APHP Beaujon Hospital , Clichy , France.,b Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies , Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot , Paris , France
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11
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Abstract
PURPOSE OF REVIEW Short bowel syndrome (SBS) is a rare disease but with many complications due to intestinal failure, parenteral nutrition and underlying disease. A better prevention, comprehension and treatment could improve the outcome of these patients. RECENT FINDINGS Recent studies have been published on acute intestinal failure, first cause of SBS, and gives us strategy to avoid extended intestinal resection and thus SBS. There has been progress in the comprehension of intestinal adaptation, characterized by improvements in intestinal absorption, changes on hormonal secretion, development of a hyperphagia and dysbiosis of the gut microbiota. Hormonal treatment focusing on intestinal rehabilitation by promoting intestinal hyperadaptation has been proposed in patients with SBS, who require parenteral nutrition and intravenous fluids, such as glucagon-like peptide-2 (GLP-2) analog which is now recommended by the latest European Society for Clinical Nutrition and Metabolism Guidelines. SUMMARY Multimodal treatment of acute meseteric ischemia may avoid intestinal resection and is an effective prevention strategy for SBS. New understandings in intestinal adaptation can help us to optimize this adaptation, including with hormonal therapy. GLP-2 analog is now the treatment of reference in SBS patients with chronic intestinal failure.
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Affiliation(s)
- Lore Billiauws
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot, Paris, France
| | - Olivier Corcos
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot, Paris, France
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12
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Jeppesen PB, Fuglsang KA. Nutritional Therapy in Adult Short Bowel Syndrome Patients with Chronic Intestinal Failure. Gastroenterol Clin North Am 2018; 47:61-75. [PMID: 29413019 DOI: 10.1016/j.gtc.2017.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Intestinal failure (IF) is the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that parenteral support (PS) is required to maintain health and/or growth. This article critically revises the gaps in and evidence for providing general nutritional therapy recommendations in the Short Bowel Syndrome-IF population. It addresses the need for an individualized approach, aiming to reduce or even eliminate the need for PS, and emphasizes a need to focus on effects of dietary interventions on the quality of life of these patients.
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Affiliation(s)
- Palle Bekker Jeppesen
- Department of Medical Gastroenterology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.
| | - Kristian Asp Fuglsang
- Department of Medical Gastroenterology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
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13
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Jeppesen PB, Gabe SM, Seidner DL, Lee HM, Olivier C. Factors Associated With Response to Teduglutide in Patients With Short-Bowel Syndrome and Intestinal Failure. Gastroenterology 2018; 154:874-885. [PMID: 29174926 DOI: 10.1053/j.gastro.2017.11.023] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/23/2017] [Accepted: 11/17/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Clinical studies showed teduglutide to increase urine production and reduce need for parenteral support volume in patients with short bowel syndrome (SBS) with intestinal failure, increasing intestinal wet weight absorption and reducing diarrhea. However, the effects of teduglutide on parenteral support vary among patients. We performed a post hoc analysis of a phase III placebo-controlled study to identify characteristics of patients in whom teduglutide has the largest effects on parenteral support volume response. METHODS We collected data from 85 patients with SBS with intestinal failure, according to the European Society for Clinical Nutrition and Metabolism classification system, who received teduglutide or placebo between November 25, 2008, and January 4, 2011, at 27 sites in 10 countries. Changes in parenteral support volume were evaluated according to baseline parenteral support volume, bowel anatomy (group 1, jejunostomy/ileostomy; group 2, ≥50% colon-in-continuity without stoma; and group 3, other colon anatomies), and disease features (with inflammatory bowel disease, mesenteric vascular diseases, or other conditions). Correlation analyses were conducted using simple linear regression models, with unadjusted r2 values reported. Two-sided t tests were used for comparisons between treatment groups. RESULTS We correlated parenteral support volume reduction with teduglutide treatment and baseline parenteral support volume (y = -0.3870x + 90.0279, r2 = 0.61; P < .0001). The effects of teduglutide on absolute parenteral support volume were significantly greater in group 1 patients (reduction of 919 ± 644 mL/d), not only compared with patients given placebo (reduction of 340 ± 436 mL/d; P = .0112) but also compared with teduglutide-treated patients in group 2 (reduction of 355 ± 306 mL/d; P = .0066). Teduglutide had an intermediate effect on patients in group 3. A minority of patients with SBS and inflammatory bowel diseases had colon-in-continuity (10.5% [n = 2/19]), whereas most patients with SBS and vascular or other diseases had colon-in-continuity (84.4% [n = 27/32] and 67.6% [n = 23/34], respectively). CONCLUSIONS In a post hoc analysis of data from a phase III study of the effects of teduglutide on patients with SBS, we associated reduced parenteral support volume with baseline parenteral support volume, bowel anatomy, and SBS features. These findings may inform initial parenteral support volume adjustments and management of these severely disabled patients. ClinicalTrials.gov no: NCT00798967; ClinicalTrialsRegister.eu no: 2008-006193-15.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark.
| | - Simon M Gabe
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Northwick Park, London, UK
| | - Douglas L Seidner
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hak-Myung Lee
- Shire Human Genetic Therapies, Inc, Lexington, Massachusetts
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14
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Billiauws L, Bataille J, Boehm V, Corcos O, Joly F. Teduglutide for treatment of adult patients with short bowel syndrome. Expert Opin Biol Ther 2017; 17:623-632. [DOI: 10.1080/14712598.2017.1304912] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Lore Billiauws
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
| | - Julie Bataille
- Hopital Beaujon - Department of Pharmacy, APHP - University Paris VII, Clichy, France
| | - Vanessa Boehm
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
| | - Olivier Corcos
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
- Laboratory for Vascular Translational Science, UFR de Médecine Paris Diderot, Paris, France
| | - Francisca Joly
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
- Centre de Recherche sur l’Inflammation, Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Paris, France
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15
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Brandt CF, Tribler S, Hvistendahl M, Staun M, Brøbech P, Jeppesen PB. Single-Center, Adult Chronic Intestinal Failure Cohort Analyzed According to the ESPEN-Endorsed Recommendations, Definitions, and Classifications. JPEN J Parenter Enteral Nutr 2015; 41:566-574. [DOI: 10.1177/0148607115612040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Siri Tribler
- Department of Medical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mark Hvistendahl
- Department of Medical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Staun
- Department of Medical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Brøbech
- Department of Medical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Palle Bekker Jeppesen
- Department of Medical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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16
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Pakarinen MP. Autologous intestinal reconstruction surgery as part of comprehensive management of intestinal failure. Pediatr Surg Int 2015; 31:453-64. [PMID: 25820764 DOI: 10.1007/s00383-015-3696-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 12/21/2022]
Abstract
Pediatric intestinal failure (IF) remains to be associated with significant morbidity and mortality, the most frequent underlying etiologies being short bowel syndrome (SBS), and primary motility disorders. Management aims to assure growth and development, while preventing complications and facilitating weaning off parenteral support (PS) by fully utilizing adaptation potential of the remaining gut. Probability of survival and weaning off PS is improved by coordinated multidisciplinary intestinal rehabilitation combining individualized physiological enteral and parenteral nutrition (PN), meticulous central line care and medical management with carefully planned surgical care. Increasing evidence suggests that autologous intestinal reconstruction (AIR) surgery is effective treatment for selected short bowel patients. Bowel lengthening procedures normalize pathological adaptation-associated short bowel dilatation with potential to support intestinal absorption and liver function by various mechanisms. Although reversed small intestinal segment, designed to prolong accelerated intestinal transit, improves absorption in adult SBS, its feasibility in children remains unclear. Controlled bowel obstruction to induce dilatation followed by bowel lengthening aims to gain extra length in patients with the shortest duodenojejunal remnant. Reduced PS requirement limits the extent of complications, improving prognosis and quality of life. The great majority of children with SBS can be weaned from PS while prognosis of intractable primary motility disorders remains poor without intestinal transplantation, which serves as a salvage therapy for life-threatening complications such as liver failure, central vein thrombosis or recurrent bloodstream infections.
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Affiliation(s)
- Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 11, Po Box 281, 00029 HUS, Helsinki, Finland,
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17
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Abstract
PURPOSE OF REVIEW The approval of teduglutide, a recombinant analog of human glucagon-like peptide (GLP) 2, by the US Food and Drug Administration (Gattex) and the European Medicines Agency (Revestive) has illustrated the potential of selected gut hormones as treatments in patients with short-bowel syndrome and intestinal failure. Gut hormones may improve the structural and functional intestinal adaptation following intestinal resection by decreasing a rapid gastric emptying and hypersecretion, by increasing the intestinal blood flow, and by promoting intestinal growth. This review summarizes the findings from phase 2 and 3 teduglutide studies, and pilot studies employing GLP-1 and agonists for this orphan condition. RECENT FINDINGS In a 3-week, phase 2, metabolic balance study, teduglutide increased the intestinal wet weight absorption by approximately 700 g/day and reduced fecal energy losses by approximately 0.8 MJ/day (∼200 Kcal/day). In two subsequent 24-week, phase 3 studies, teduglutide reduced the need for parenteral support in the same magnitude. Adverse events were mainly of gastrointestinal origin and consistent with the known mechanism of action of teduglutide. Pilot studies suggest that GLP-1 may be less potent. Synergistic effects may be seen by co-treatment with GLP-2. SUMMARY Gut hormones promote intestinal adaptation and absorption, decreasing fecal losses, thereby decreasing or even eliminating the need for parenteral support. This will aid the intestinal rehabilitation in these severely disabled short-bowel syndrome patients.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology CA-2121, Rigshospitalet, Copenhagen, Denmark
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18
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ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults. Clin Nutr 2014; 34:171-80. [PMID: 25311444 DOI: 10.1016/j.clnu.2014.08.017] [Citation(s) in RCA: 361] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/20/2014] [Accepted: 08/23/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Intestinal failure (IF) is not included in the list of PubMed Mesh terms, as failure is the term describing a state of non functioning of other organs, and as such is not well recognized. No scientific society has yet devised a formal definition and classification of IF. The European Society for Clinical Nutrition and Metabolism guideline committee endorsed its "home artificial nutrition and chronic IF" and "acute IF" special interest groups to write recommendations on these issues. METHODS After a Medline Search, in December 2013, for "intestinal failure" and "review"[Publication Type], the project was developed using the Delphi round methodology. The final consensus was reached on March 2014, after 5 Delphi rounds and two live meetings. RESULTS The recommendations comprise the definition of IF, a functional and a pathophysiological classification for both acute and chronic IF and a clinical classification of chronic IF. IF was defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". CONCLUSIONS This formal definition and classification of IF, will facilitate communication and cooperation among professionals in clinical practice, organization and management, and research.
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Jeppesen PB. Pharmacologic options for intestinal rehabilitation in patients with short bowel syndrome. JPEN J Parenter Enteral Nutr 2014; 38:45S-52S. [PMID: 24615689 DOI: 10.1177/0148607114526241] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A primary goal of intestinal rehabilitation programs is to facilitate intestinal adaptation. Adult patients with short bowel syndrome (SBS) who are dependent on parenteral nutrition and/or intravenous fluid (PN/IV) support have 2 hormonal pharmacologic treatment options available that may promote intestinal growth: a glucagon-like peptide 2 analog (teduglutide) and recombinant human growth hormone (somatropin). In two phase III clinical trials (N=169), 24 weeks of teduglutide administered to outpatients with SBS resulted in significant decreases in PN/IV volume requirements of 2.5-4.4 L/wk. In an extension study of one of these trials, patients with SBS who completed 30 months of teduglutide experienced a mean PN/IV reduction of 7.6 L/wk from baseline. Furthermore, some patients achieved independence from PN/IV support. The most common adverse events associated with teduglutide treatment in clinical trials were gastrointestinal symptoms, including abdominal distension, abdominal pain, and nausea. This safety profile is consistent with the associated underlying diseases leading to SBS or the known mechanism of action of teduglutide. A single phase III study (N=41) evaluated the safety and efficacy of a 4-week inpatient course of somatropin in combination with a glutamine-supplemented diet for adults with SBS. Somatropin treatment significantly reduced parenteral support requirements by 1.1 L/d in these patients. The most common adverse events were peripheral edema and musculoskeletal events. Large-scale, long-term follow-up studies of somatropin for SBS have not been conducted. Although treatment for patients with SBS must be individualized, teduglutide and somatropin are positive extensions to existing fluid and nutrient management strategies.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
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20
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Abstract
PURPOSE OF REVIEW Teduglutide, a recombinant analog of human glucagon-like peptide 2, has recently been approved in the US and Europe (Gattex and Revestive, respectively) as the first targeted treatment of short bowel syndrome-associated intestinal failure (SBS-IF). Glucagon-like peptide 2 improves structural and functional intestinal adaptation following intestinal resection by decelerating a rapid gastric emptying, by decreasing gastric hypersecretion, by increasing intestinal blood flow and by promoting intestinal growth. This review summarizes the findings from phase 2 and 3 studies preceding the US Food and Drug Administration and the European Medicines Agency approval of subcutaneous teduglutide for this orphan condition. RECENT FINDINGS In a 3-week, phase 2, metabolic balance study, teduglutide increased intestinal wet weight absorption by approximately 700 g/day and reduced fecal energy losses by approximately 0.8 MJ/day (∼200 kcal/day). In two subsequent 24-week, phase 3 studies, teduglutide reduced the need for parenteral support in the same magnitude. Teduglutide had an acceptable tolerability profile, where adverse events generally were of gastrointestinal origin consistent with the known mechanism of action. SUMMARY Teduglutide will add incremental benefit to the limited medical treatment armamentarium in SBS patients by maximizing intestinal absorption, decreasing fecal losses, thereby decreasing or even eliminating the need for parenteral support. Future research should target and implement other key hormones with similar and possible additive or synergistic effects, thereby further promoting structural and functional adaptation and intestinal rehabilitation in these severely disabled SBS patients.
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Jeppesen PB. Spectrum of short bowel syndrome in adults: intestinal insufficiency to intestinal failure. JPEN J Parenter Enteral Nutr 2014; 38:8S-13S. [PMID: 24486858 DOI: 10.1177/0148607114520994] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Short bowel syndrome (SBS) refers to the malabsorptive state caused by physical or functional loss of portions of the small intestine, most commonly following extensive intestinal resection. Such resections hinder absorption of adequate amounts of macronutrients, micronutrients, electrolytes, and water, resulting in malnutrition, diarrhea, and dehydration. Clinical features of SBS vary along a continuum, depending on the extent and anatomy of intestine lost and the ability of the patient and the remaining intestine to compensate for the loss. The impact of SBS can be extensive, leading to diminished health-related quality of life because of its many physical and psychological effects on patients. SBS is associated with decreased survival; risk factors for SBS-related mortality include very short remnant small bowel, end-jejunal remnant anatomy, and arterial mesenteric infarction as primary cause. Although parenteral nutrition and/or intravenous fluid (PN/IV) is a life-saving measure for many patients with SBS, patients with the most severe malabsorption (ie, dependent on PN/IV) are at risk for severe, chronic complications and death. Patients' treatment needs vary depending on disease severity and resection type; thus, each patient should be individually managed. This review discusses the spectrum of disease in patients with SBS and presents common complications encountered by these patients to highlight the importance of individualized management and treatment.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW Recently, the US Food and Drug Administration and the European Medicines Agency approved the glucagon-like peptide 2 analogue, teduglutide, for the treatment of short bowel syndrome (SBS), and this review describes the physiological basis for its clinical use. RECENT FINDINGS By affecting the intestinal neuroendocrine system, hormones may promote the growth of the intestinal mucosa, restore a more normal gastric emptying and secretion, stimulate intestinal blood flow, increase intestinal barrier function, immunity and absorption, and thereby promote structural and functional adaptation following intestinal resection. In a 3-week, phase 2, metabolic balance study, teduglutide increased intestinal wet weight absorption by ∼700 g/day and reduced faecal energy losses by ∼0.8 MJ/day. In two subsequent 24-week, phase 3 studies in SBS patients with intestinal failure (SBS-IF), teduglutide reduced the need for parenteral support in the same magnitude. SUMMARY Teduglutide adds incremental benefit to the limited medical treatment armamentarium in SBS patients. Modern treatments should aim to maximize remnant intestinal absorption, decrease malabsorption and accompanying symptoms, reduce the need, burdens and complications related to parenteral support, and ultimately improve the health-related quality of life in SBS-IF patients. Future research should target and implement other key hormones with similar effects, thereby promoting intestinal adaptation and rehabilitation in SBS patients.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark.
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