How important is onset of action in ulcerative colitis therapy?

Early onset of efficacy in patients with functional and motility-related gastrointestinal disorders : A noninterventional study with Iberogast®

STW 5 (Iberogast®; Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany) contains nine plant extracts and possesses well-documented overall efficacy in functional gastrointestinal disorders (FGID). Little is known about the onset of symptom relief. Twenty-nine centers in Germany recruited 272 patients with established FGID. These patients were treated with STW 5 for approximately 3 weeks in this noninterventional study. Patients assessed the severity of their gastrointestinal complaints before and at defined times after the intake of STW 5 (10 cm visual analogue scale; VAS). Fifteen minutes after the first dose, the severity of gastrointestinal complaints had decreased by 1.4 cm (mean; initial mean: 5.2 of 10 cm). After 1 h, more than 90% of the maximum effect of 3.2 cm on the 10 cm VAS had been reached. Most patients with symptoms experienced a marked improvement within 5, 15 or 30 min of taking STW 5. Absolute improvements were larger in patients with more pronounced baseline complaints. Subgroups with upper (80% of the study population) and lower FGID (20%) did not present major differences. Neither did subgroups by age and duration of complaints. Treatment with STW 5 resulted in rapid improvement of symptoms.

Effects of oral tacrolimus as a rapid induction therapy in ulcerative colitis

AIM: To determine the efficacy and safety of rapid induction therapy with oral tacrolimus without a meal in steroid-refractory ulcerative colitis (UC) patients.

METHODS: This was a prospective, multicenter, observational study. Between May 2010 and August 2012, 49 steroid-refractory UC patients (55 flare-ups) were consecutively enrolled. All patients were treated with oral tacrolimus without a meal at an initial dose of 0.1 mg/kg per day. The dose was adjusted to maintain trough whole-blood levels of 10-15 ng/mL for the first 2 wk. Induction of remission at 2 and 4 wk after tacrolimus treatment initiation was evaluated using Lichtiger’s clinical activity index (CAI).

RESULTS: The mean CAI was 12.6 ± 3.6 at onset. Within the first 7 d, 93.5% of patients maintained high trough levels (10-15 ng/mL). The CAI significantly decreased beginning 2 d after treatment initiation. At 2 wk, 73.1% of patients experienced clinical responses. After tacrolimus initiation, 31.4% and 75.6% of patients achieved clinical remission at 2 and 4 wk, respectively. Treatment was well tolerated.

CONCLUSION: Rapid induction therapy with oral tacrolimus shortened the time to achievement of appropriate trough levels and demonstrated a high remission rate 28 d after treatment initiation. Rapid induction therapy with oral tacrolimus appears to be a useful therapy for the treatment of refractory UC.

Balsalazide in treating colonic diseases

Balsalazide is the newer 5-aminosalicylic acid (5-ASA) prodrug which releases active 5-ASA only into the colon with minimal systemic absorption. The onset of action of this drug is variable, and it may take at least some days to reach clinical effectiveness. Clinical studies found balsalazide faster than mesalazine in the induction of remission, but balsalazide has no benefit compared with mesalazine in preventing relapse in the population selected. However, the high number of pills to take may affect the adherence to the treatment. This 5-ASA prodrug may be effectively used also in patients unable to tolerate other mesalamine compounds for non-hypersensitivity reasons. The costs of balsalazide capsules seem to be lower for the health system, both considering total direct healthcare costs and better outcomes, compared with patients treated with oral mesalazine. Finally, there is also some recent evidence that balsalazide may be effectively used, in combination with probiotics, in treating acute uncomplicated diverticulitis is the colon.