Efficacy and tolerability of exclusive enteral nutrition in adult patients with complicated Crohn's disease

Progress and Clinical Applications of Crohn's Disease Exclusion Diet in Crohn's Disease

Crohn's disease is a chronic intestinal inflammatory disorder of unknown etiology. Although the pharmacotherapies for Crohn's disease are constantly updating, nutritional support and adjuvant therapies have recently gained more attention. Due to advancements in clinical nutrition, various clinical nutritional therapies are used to treat Crohn's disease. Doctors treating inflammatory bowel disease can now offer several diets with more flexibility than ever. The Crohn's disease exclusion diet is a widely used diet for patients with active Crohn's disease. The Crohn's disease exclusion diet requires both exclusion and inclusion. Periodic exclusion of harmful foods and inclusion of wholesome foods gradually improves a patient's nutritional status. This article reviews the Crohn's disease exclusion diet, including its structure, mechanisms, research findings, and clinical applications.

Exclusive Enteral Nutrition Orchestrates Immunological Balances as Early as Week 4 in Adult Patients of Crohn's Disease: A Pilot, Open-Lable Study

BACKGROUND AND AIMS

The efficacy and underlying mechanisms of exclusive enteral nutrition (EEN) in adult patients with Crohn's disease (CD) remain controversial. This study aimed to evaluate the role of EEN in adult patients with CD and to explore the mechanisms from the perspective of immunoregulation.

METHODS

This is a prospective, open-label pilot study. Active patients with CD were enrolled and prescribed an amino-acid-rich elemental diet for 12 weeks. Dynamic changes in immune cells, including neutrophils, monocytes, T cells and B cells, were detected by flow cytometry. Plasma cytokines were evaluated by ELISA.

RESULTS

Twenty adult patients with CD were enrolled. Among them, 1 discontinued treatment due to poor compliance, and 19 patients were included for final analysis. Clinical remission was achieved in 47.37% (9/19), 63.16% (12/19), and 73.68% (14/19) patients at weeks 4, 8, and 12, respectively. Endoscopic remission and transmural healing were achieved in 52.63% (10/19) and 15.79% (3/19) patients at week 12. Notably, there was no significant difference in clinical remission between week 4 and week 8 (p = 0.33) or week 12 (p = 0.09). Furthermore, we observed a rapid reconstitution of immunologic homeostasis as early as week 4. At week 4, both the frequency and activation of neutrophils and monocytes were decreased after EEN therapy. Significant decreases in Th17 cells and naïve B cells, increases in memory B cells, and regulatory B cells were also detected. These changes remained stable at weeks 8 and 12.

CONCLUSIONS

EEN with an amino-acid-rich elemental diet orchestrated immunological balances and induces clinical remission in adult CD patients as early as week 4, suggesting a 4-week EEN therapy may be feasible and practicable in clinical practice.

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease

Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.

Exclusive Enteral Nutrition in Adult Crohn's Disease: an Overview of Clinical Practice and Perceived Barriers

Recently, the role of nutrition in the management of Crohn's disease (CD) is of increasing interest and the exploration of novel nutritional interventions to improve long-term management of the disease is challenging. So far, the majority of the studies on the role of exclusive enteral nutrition (EEN) in CD are conducted in the pediatric population and have highlighted the efficacy of EEN for achieving mucosal healing. This implicates that a similar approach would be beneficial in adult patients. However, the evidence for EEN in adults is heterogeneous, with meta-analyses reporting it as inferior to steroids while growing data demonstrate improvement in complicated CD. Currently, EEN is less used in adult patients with IBD. Indeed, the lack of palatability of enteral formula leads to difficulties in acceptance and compliance. The search for more tolerable and still effective diets has become an intense area of research aiming to explore the potential role of diet to control inflammation in patients with CD. Thus, this narrative review provides the state-of-the-art on the use of EEN treatment in CD and highlights the perceived barriers to its implementation in adult CD patients.

Is frequency of dietitian support associated with greater clinical improvements in adults with Crohn's disease undertaking Exclusive Enteral Nutrition (EEN)?

INTRODUCTION

Exclusive enteral nutrition (EEN) is considered an effective, low-risk therapy in the treatment of Crohn's Disease (CD). Frequent dietetic support may assistadults to succeed. This observational study aimed to compare whether frequency of dietetic support during EEN therapy was associated with differences in clinical and nutritional outcomes across two gastroenterologyinflammatory bowel disease services. Site Aprovided ≥3 visits plus more if clinically indicated and Site B provided weekly support.

METHODS

Eligible patients were adults with active CD recommended to be treated with oral EEN for ≥6weeks between February 2018 to December 2019.Demographic, anthropometric, clinical, medications, pathology and EEN treatment descriptors were sourced from the medical chart. Descriptive statistics, chi-squared and t-tests were used to compare data between sites.

RESULTS

Eighty-four CD patients were eligible (44±14yrs, 54% female, baseline Crohn's Disease Activity Index (CDAI) 259.5±113.1, n=51Site A) and completed EEN for median(range) 6.1(1-12) weeks. Most patients (82%, n=69/84) completed ≥6 weeks of EEN treatment. CDAI score and calprotectin improved across the total sample from pre- to post-EEN by -109.8±92.1 (p<0.001) and -65µg/g(-65230-4370) (p=0.002), respectively. Dietitian occasions of service were more frequent at Site B (7(4-12) occasions vs. 3(1-8), p<0.001). However, changes in clinicaland biomarker datawere similar between sites (p<0.05).

CONCLUSIONS

EEN with regular dietetic input resulted in clinical and biochemical improvements for patients with active CD. Tailoring dietetic support based on the client'sneeds and preference may achieve similar clinical improvements as providing weekly dietetic support to adults on EEN. This article is protected by copyright. All rights reserved.

Current Use of EEN in Pre-Operative Optimisation in Crohn's Disease

Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.

Exclusive enteral nutrition with oral polymeric diet helps in inducing clinical and biochemical remission in adults with active Crohn's Disease

BACKGROUND AND AIMS

Exclusive enteral nutrition (EEN) is not routinely used as induction therapy for adults with active Crohn's Disease (CD). The aim of this study was to assess the effectiveness of EEN with oral polymeric formula as an adjunct for inducing clinical and biochemical remission in adults with active CD.

METHODS

We performed a retrospective analysis of data from January 2018 to September 2019 on all patients with active CD who commenced EEN. Primary endpoint was clinical remission (CDAI ≤150) or response (100-point decrease in CDAI) at 8 weeks. Secondary endpoint was achievement of biochemical remission (CRP ≤5 mg/L or faeces calprotectin ≤150 mcg/g) at 8 weeks in those whose baseline values were elevated. We also aimed to identify predictors of response to EEN therapy.

RESULTS

Sixty-six patients commenced EEN, 53/66 (80.3%) completed the prescribed EEN course. At 8 weeks, 42/66 (63.6%) patients achieved primary endpoint and secondary endpoint was achieved in 30/53 (56.6%) of patients. Patients receiving EEN for ≥ 6 weeks achieved primary (72% vs 47.8%, OR 2.8, p = 0.047, CI 0.97 -8.16) and secondary endpoint (67.6% vs 36.8%, OR 3.58, p = 0.035, CI 1.1- 11.63) more frequently when compared with patients who received EEN for <6 weeks. Nine patients reported adverse effects (4 nausea,3 diarrhoea,1 constipation and 1 abdominal pain), none of whom ceased therapy.

CONCLUSION

Polymeric EEN is well tolerated, safe and effective in inducing clinical and biochemical remission in adults with active CD. EEN duration of ≥ 6 weeks has better outcomes. This article is protected by copyright. All rights reserved.

Review of exclusive enteral therapy in adult Crohn's disease

Background

Exclusive enteral nutrition (EEN) is a potentially effective but underused therapy for Crohn’s disease (CD) in adults. It is first-line induction treatment for paediatric patients but remains a second-line or third-line therapy in adults.

Objective

To analyse the evidence for EEN in adult patients with CD, and summarise this in a narrative review.

Methods

In April/May 2020 and July 2021, a literature search was performed using the Medical Subject Headings (MeSH) terms: ‘Crohn’s disease’, ‘CD’, ‘inflammatory bowel disease’, ‘IBD’, ‘exclusive enteral nutrition’, ‘enteral nutrition’, ‘EEN’, in PubMed, Scopus, Cochrane. Additional studies were obtained from references of search result articles as well as general reading. Studies with adult patients with CD treated with EEN were selected. 79 articles of relevance were found. Where data in adults were lacking, data from paediatric studies as extrapolated with care.

Results

EEN in adult patients been shown to improve clinical, biomarker, endoscopic and radiologic measures of disease activity. EEN avoids the potential adverse effects of recurrent corticosteroids for induction such as metabolic derangements and opportunistic infections. EEN has also demonstrated benefits among adult patients with fistulising and stricturing CD. It may avoid surgery in such patients. Preoperative EEN has also been shown to reduce postoperative complications and recurrence. There appears to be benefits in combing EEN with antitumour necrosis factor agents, however, benefits of combination therapy with other biologics are less clear. A major drawback of EEN therapy in adults has been poor compliance. More palatable polymeric formulations improved patient education and dietitian support may overcome this. Evidence in adults is limited to small studies, often with suboptimal control arms and lack of blinding. Larger scale studies with improved study design are needed to confirm these beneficial effects.

Conclusion

Despite limitations in evidence EEN should be considered in treating adults with CD.

Diet and nutrition in the management of inflammatory bowel disease

The role of diet and its manipulation in the management of inflammatory bowel disease (IBD) is gradually acquiring central stage. Certain dietary factors have been identified as putative triggers in IBD as some other factors are found to be protective. The dietary manipulation as part of comprehensive IBD care should be done by the clinician in conjunction with a skilled dietitian. Nutritional deficiencies are common in patients with IBD and can have long-term effects on disease course and quality of life in these patients. So, early identification and correction of these deficiencies along with proper nutritional supplementation should be addressed routinely as a part of IBD management. Oral nutritional supplementation is sufficient for most patients, but in some sick patients, tube feeding may be necessary. Diet needs to be individualized based on the nutritional deficiencies and dietary triggers in a specific patient. Multiple specific diets, with elimination of components that trigger inflammation or addition of components that alter gut microbes in a favorable way, are now appearing as a treatment option in IBD, but more evidence is required before their universal recommendation. Though enteral nutrition (EN) (both exclusive enteral nutrition [EEN] and partial enteral nutrition [PEN]) have proven therapeutic role in pediatric IBD, their uses and role are now expanding in adult IBD patients as well.

EEN Yesterday and Today … CDED Today and Tomorrow

The treatment of Pediatric Crohn’s Disease (CD) requires attention both to achieve mucosal healing and to optimize growth, while also maintaining proper bone health. Exclusive Enteral Nutrition (EEN) is recommended as first-line treatment in luminal CD. The therapeutic mechanisms of EEN are being discovered by advances in the study of the gut microbiota. Although the total exclusion of a normal diet during the time of EEN continues to be of high importance, new modalities of dietary treatment suggest a successful future for the nutritional management of CD. In this sense, Crohn’s Disease Exclusion Diet (CDED) is a long-term strategy, it apparently acts on the mechanisms that influence the appearance of inflammation (reducing dietary exposure to products negatively affecting the microbiota), but does so using specific available whole foods to achieve this goal, increases the time of clinical remission and promotes healthy lifestyle habits. The development of CDED, which partly minimizes the problems of EEN, has enabled a turnaround in the treatment of pediatric CD. This review highlights the role of enteral nutrition in the treatment of Crohn’s disease with special emphasis on newer dietary modalities such as CDED.

Making Decisions about Dietary Therapy in Inflammatory Bowel Disease

Treatment for inflammatory bowel disease (IBD) deserves an informed shared decision-making process between patient and doctor. IBD spans a spectrum of phenotypes that impact each patient uniquely. While treatment has primarily consisted of medical or surgical therapy, dietary approaches have become increasingly relevant. A majority of patients with IBD use some form of dietary modification, and it is common for patients to do this without their physicians’ knowledge. Lack of medical supervision can lead to nutritional deficiencies and a worsening disease state. Some patients work with their medical team to pursue a well-defined exclusion diet as a primary therapy, such as the specific carbohydrate diet, exclusive enteral nutrition, or the Crohn’s disease exclusion diet. The motivations to use dietary therapy for IBD remain unclear and the effectiveness has not been definitively established for many approaches. It is necessary for medical providers to be knowledgeable and to foster open communication with their patients in order to ensure the highest likelihood of remission. This review provides an overview of dietary treatment options, the current knowledge about patient motivations for pursuing dietary therapy, and the roles of patient empowerment and patient activation. We outline areas of improvement for the decision-making process.