Conventional therapy for Crohn’s disease

Bipolymeric Pectin Millibeads Doped with Functional Polymers as Matrices for the Controlled and Targeted Release of Mesalazine

Targeted drug delivery systems are a very convenient method of treating inflammatory bowel disease. The properties of pectin make this biopolymer a suitable drug carrier. These properties allow pectin to overcome the diverse environment of the digestive tract and deliver the drug to the large intestine. This investigation proposed bipolymeric formulations consisting of the natural polymer pectin and a synthetic polymer containing the drug 5-aminosalicylic acid. Pectin beads were prepared via ionotropic gelation involving the interaction between the hydrophilic gel and calcium ions. The obtained formulations consisted of natural polymer, 5-aminosalicylic acid (5-ASA) and one of the synthetic polymers, such as polyacrylic acid, polyvinylpyrrolidone, polyethylene glycol or aristoflex. The release of the drug was carried out employing a basket apparatus (USP 1). The acceptor fluid was pH = 7.4 buffer with added enzyme pectinase to reflect the colon environment. The amount of the released drug was determined using UV-Vis spectrophotometry at a wavelength of λ = 330 nm. The kinetics of the drug dissolution revealed that none of the employed models was appropriate to describe the release process. A kinetic analysis of the release profile during two release stages was carried out. The fastest drug release occurred during the first stage from a formulation containing pectin and polyethylene glycol. However, according to the applied kinetic models, the dissolution of 5-ASA was rather high in the formulation without the synthetic polymer during the second stage. Depending on the formulation, 68-77% of 5-ASA was released in an 8-hour time period. The FTIR and DSC results showed that there was no interaction between the drug and the polymers, but interactions between pectin and synthetic polymers were found.

Medical Management of Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory bowel disease that can affect the entire gastrointestinal tract from the mouth to the anus, sparing the rectum. The goal of medical therapy is to induce remission with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important, as there is an overlap of medications used to induce and maintain remission. Physicians first direct treatment to induce a remission that involves relief of symptoms and mucosal healing of the lining of the colon and then provide long-term treatment to maintain the remission. Standard treatment for CD depends on the extent of involvement and disease severity, for example, mild, moderate, severe, and fulminant.

Potentially avoidable surgery in inflammatory bowel disease: what proportion of patients come to resection without optimal preoperative therapy? A guidelines-based audit

BACKGROUND

Recently, promulgated inflammatory bowel disease (IBD) guidelines seek to decrease the need for surgery by improving disease control. However, resection rates remain static.

AIMS

We therefore sought to determine the proportion of patients coming to surgery where preoperative management was not optimal according to guidelines.

METHODS

Case notes of all patients with resection surgery for IBD from January 2007 to March 2008 at a metropolitan teaching hospital were retrospectively reviewed. Judgement was made as to whether preoperative management was optimal or suboptimal depending on whether it met guidelines.

RESULTS

A total of 22 subjects with IBD-related resections were identified (15 males and seven females). In total, 17 had Crohn's disease (CD) (11 males) and five ulcerative colitis (UC) (four males). There were 10 smokers (nine CD and one UC). The two most common indications for surgery were inflammatory mass/abscess (n= 8) and refractory to medical therapy (n= 7). While all patients with known IBD (20/22) had seen a gastroenterologist in the past, five known IBD patients had resections undertaken without preoperative gastroenterologist input. Overall preoperative management was judged as optimal in only (9/22) 41%. Of those whose therapy did not meet guidelines (n= 13), five had azathioprine at doses <2 mg/kg, one declined therapy and nine with CD were current smokers.

CONCLUSIONS

Over 50% of IBD resection patients had suboptimal preoperative management, with sub-therapeutic thiopurine dosing and smoking in CD the main problems. Thus, there are significant gains to be made with better use of standard therapies, as it appears that ∼50% of resection surgery was 'potentially avoidable'.

Adjunctive antibiotic therapy with rifaximin may help reduce Crohn's disease activity

AIMS

Enteric bacteria are thought to contribute to the pathogenesis of Crohn's disease, and antibiotics may be an effective therapy. This study examines the efficacy of the nonsystemic (<0.4% absorbed) antibiotic rifaximin for inducing remission in patients with Crohn's disease.

METHODS

Data from charts of patients with Crohn's disease who received rifaximin between 2001 and 2005 and had a Crohn's disease activity index score > or =220 at the time of rifaximin initiation were analyzed. The use of concomitant medications (e.g., steroids, anti-inflammatory agents) was allowed.

RESULTS

In the 68 patient charts analyzed, the median duration of rifaximin treatment was 16.6 weeks, and the majority of patients (94%) received rifaximin 600 mg/day. Eighteen patients (26%) received rifaximin monotherapy, and 31 patients (46%) received concomitant steroids. The median baseline Crohn's disease activity index score at the time of rifaximin initiation was 265 (range, 220-460), and the mean duration of Crohn's disease was 17 years (range, 1-50 years). Crohn's disease remission occurred in 65% of patients. A 70% remission rate was achieved in patients who did not receive steroids, versus 58% in patients who received steroids. Clinical improvements continued 4 months after rifaximin initiation. Remission was achieved in 67% of patients who received rifaximin monotherapy.

CONCLUSIONS

Rifaximin therapy was associated with clinical improvement in patients with Crohn's disease and may be a useful treatment option to consider for inducing and maintaining remission.

Inflammatory bowel disease

Inflammatory bowel diseases (IBDs) encompass ulcerative colitis, Crohn's disease, and indeterminate colitis, all of which are characterized by remission and exacerbation of gastrointestinal symptoms, and a variety of extraintestinal manifestations including those affecting the oral cavity. Although not particularly a cause for mortality, inflammatory bowel diseases are associated with significant morbidity and impact on the quality of life. This article reviews clinical presentation, diagnostic criteria, and therapeutic modalities for the 2 main types of inflammatory bowel disease and discusses manifestations of these conditions in the oral cavity. The role of the oral health care provider in timely recognition and referral for medical work-up as well as management of oral complaints is also emphasized.

Health-related quality-of-life evaluation of crohn disease patients after receiving natalizumab therapy

Crohn disease (CD) is a chronic inflammatory condition without a permanent medical cure and commonly requiring a lifetime of care. This article discusses the impact of natalizumab induction and maintenance therapy on the health-related quality of life (HRQoL) of CD patients. Two natalizumab phase III studies were evaluated: the Efficacy of Natalizumab in Crohn's Disease Response and Remission (ENCORE) study evaluated the HRQoL of CD patients during 12 weeks of natalizumab induction therapy, and the Evaluation of Natalizumab As Continuous Therapy (ENACT-2) trial evaluated the effect of natalizumab maintenance therapy on HRQoL for a period of 48 weeks past a 12-week induction period (ENACT-1). HRQoL assessments were made with the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Short Form-36 (SF-36). In the ENCORE study, induction therapy with natalizumab was demonstrated to significantly increase HRQoL scores at 12 weeks when compared with patients on placebo. During the ENACT-2 trial, IBDQ and SF-36 scale scores of patients who responded to natalizumab induction remained stable whereas those on placebo worsened. At week 60, the mean change from baseline on all scales of the IBDQ and the SF-36 were significantly higher for those who continued to receive natalizumab as compared to those who received placebo (p </= .016 for all scales). Natalizumab significantly improved the patient's clinical status and HRQoL shortly after treatment was initiated, and the effect was maintained for 60 weeks.

Common Pitfalls in Management of Inflammatory Bowel Disease

Our understanding of inflammatory bowel disease (IBD), treatment options, complications and their management has expanded significantly over the past few decades. When caring for patients it is important to remember the complexities of pathogenesis and pharmacology. This review is to identify errors in diagnosis, treatment, complications and preventive care issues that arise while caring for patients with IBD and to provide recommendations and information that can be shared with patients and their health care providers. A review of the literature was undertaken using MEDLINE from 1981 to present. We included randomized controlled studies, case-control studies, and review articles. There are many associated conditions and complications recognized in patients with IBD and current treatment strategies do result in many side effects, some are serious and some are not widely recognized. With the advent of anti-TNF therapies and the newer 5-amino salicylate derivatives, options available have increased significantly. It is also important to remember that these patients are followed by more than one health care provider and it is important for all involved to communicate the plan of action.

Interferon beta-1a for the maintenance of remission in patients with Crohn's disease: results of a phase II dose-finding study

BACKGROUND

Crohn's disease (CD) and multiple sclerosis (MS) share common pathogenic processes. Interferon (IFN) beta-1a is effective and generally well tolerated in patients with MS and has been shown to down-regulate the expression of interleukin-12, a cytokine that is thought to be involved in mucosal degeneration in CD. IFN beta-1a therefore offers promise as a treatment for CD.

METHODS

In this multicentre, double-blind, placebo-controlled, phase II, dose-finding study, patients with steroid-induced clinical remissions of CD were randomized 1:1:1:1 to subcutaneous IFN beta-1a: 66 mcg three times weekly (tiw), 44 mcg tiw, 44 mcg twice weekly (biw), or matching placebo tiw with steroid tapering. The primary endpoint was the proportion of patients relapse-free at Week 26. Safety was also assessed.

RESULTS

This study was terminated early following a planned interim analysis at 26 weeks. Of the planned 192 patients, 67 were randomized to treatment: placebo (n = 16), or IFN beta-1a 44 mcg biw (n = 17), 44 mcg tiw (n = 16) or 66 mcg tiw (n = 18). In total, 20/67 patients (29.9%) completed 26 weeks and 7 patients (10.4%) completed 52 weeks. The proportion of patients who remained relapse-free at Week 26 did not differ significantly between the placebo group (5/16, 31%) and the IFN beta-1a 44 mcg biw (6/17, 35%; p = 0.497), 44 mcg tiw (7/16, 44%; p = 0.280) or 66 mcg tiw (2/18, 11%; p = 0.333) groups. There was little difference between treatment groups in secondary efficacy endpoints. IFN beta-1a was generally well tolerated at all doses. Adverse events (AEs) were generally mild or moderate in IFN beta-1a-treated patients, with the most common AEs (influenza-like symptoms, headache, injection-site reactions) being similar to those reported with IFN beta-1a in MS.

CONCLUSION

There was no difference in efficacy between patients with CD receiving IFN beta-1a or placebo. However, these results should be considered in the context of the low patient numbers and high dropout rate. Overall, IFN beta-1a was generally well tolerated, with a safety profile that was consistent with previous experience in MS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00304252.

Decoy oligodeoxynucleotide targeting activator protein-1 (AP-1) attenuates intestinal inflammation in murine experimental colitis

Various therapies are used for inflammatory bowel diseases (IBD), though none seem to be extremely effective. AP-1 is a major transcription factor that upregulates genes involved in immune and proinflammatory responses. We investigated decoy oligodeoxynucleotide (ODN) targeting AP-1 to prevent dextran sulfate sodium (DSS)-induced colitis in mice. Functional efficacies of synthetic decoy and scrambled ODNs were evaluated in vitro by a reporter gene luciferase assay and measuring flagellin-induced IL-8 expression by HCT-15 cells transfected with ODNs. Experimental colitis was induced in mice with a 2.5% DSS solution in drinking water for 7 days, and decoy or scrambled ODNs were intraperitoneally injected from days 2 to 5. Colitis was assessed by weight loss, colon length, histopathology, and detection of myeloperoxidase (MPO), IL-1beta, and TNF-alpha in colon tissue. Therapeutic effects of AP-1 and NF-kappaB decoy ODNs were compared. Transfection of AP-1 decoy ODN inhibited AP-1 transcriptional activity in reporter assays and flagellin-induced IL-8 production in vitro. In mice, AP-1 decoy ODN, but not scrambled ODN, significantly inhibited weight loss, colon shortening, and histological inflammation induced by DSS. Further, AP-1 decoy ODN decreased MPO, IL-1beta, and TNF-alpha in colonic tissue of mice with DSS-induced colitis. The AP-1 decoy therapeutic effect was comparable to that of NF-kappaB decoy ODN, which also significantly decreased intestinal inflammation. Double-strand decoy ODN targeting AP-1 effectively attenuated intestinal inflammation associated with experimental colitis in mice, indicating the potential of targeting proinflammatory transcription factors in new therapies for IBD.