IBD Watch®
Timely Information for Practicing Physicians
|
|
OCTOBER 2007 Enteral nutrition (EN) as therapy in children with Crohn’s
disease (CD). Dziechciarz and others performed a meta-analysis to
review the effectiveness of EN in the management of active CD in children.
Eleven randomized clinical trials involving a total of 394 children, and culled
from a literature search of MEDLINE, EMBASE, and the Cochrane library up to
February 2007, were included in the study. Seven studies (n = 204) compared EN
to corticosteroid therapy. Pooled results from four studies (n = 144) did not
reveal a significant difference in remission rates between EN and corticosteroid
treatment (relative risk, 0.97; 95% confidence interval [CI], 0.7 to 1.4). One
study (n = 50) showed a significant increase in the remission rate in the
treatment group receiving total EN compared with children receiving partial EN.
These limited data indicate similar efficacy for EN and corticosteroids in the
treatment of children with active CD. The authors suggest that future trials
focus on detailed outcome measurements including growth and quality of life. (Dziechciarz
P, Aliment Pharmacol Ther.
2007;26:795–806.) Increased risk for carcinoid tumors. West
and colleagues reviewed the medical charts of 111 patients with CD who had
undergone a resection at their institution between June 2001 and March 2005.
Four cases of carcinoid tumor were discovered (3.6% incidence; one cecal, one
transverse colon, two appendiceal). None of the carcinoid tumors developed in
areas of CD. In comparison, 3 (0.25%) of 1,199 patients who had undergone
appendectomies were found to have appendiceal carcinoid tumors (P <0.0001). These findings suggest that patients with CD may be
at an increased risk of developing carcinoid tumors due to distant
proinflammatory mediators. ( Adalimumab maintenance therapy. Sandborn
and co-workers conducted a study in which 276 patients with moderate to severe
CD who had received induction therapy with adalimumab (the CLASSIC I trial) went
on to undergo maintenance treatment with adalimumab, 40 mg at weeks 0 and 2 (the
CLASSIC II trial). Of these patients, 55 who were in remission at both weeks 0
and 2 were randomized to receive adalimumab, 40 mg every other week, adalimumab
40 mg weekly, or placebo, for 56 weeks. Patients not in remission at both weeks
0 and 2 received adalimumab, 40 mg every other week. Among the 55 randomized
patients, the remission rates were 79%, 83%, and 44% in the adalimumab every
other week, adalimumab weekly, and placebo groups, respectively (P
= 0.05). Of 204 patients who received open-label adalimumab, 93 (46%) were in
clinical remission at week 56. Adalimumab was well tolerated. This study
demonstrated that adalimumab is an effective maintenance therapy for patients
with CD. (Sandborn W, et al. Gut.
2007;56:1232–1239.) Immunosuppressive therapy reduces the formation of antibodies
to infliximab. Episodic infliximab treatments can be
associated with the formation of antibodies to infliximab (ATIs), which can lead
to a shorter duration of response and infusion reactions. Vermeire and others
prospectively studied a cohort of 174 patients with CD who were treated with
infliximab on demand and received no immunosuppressive therapy (n = 59) or
immunosuppressive therapy with concomitant methotrexate (MTX) (n = 50) or
azathioprine (AZA) (n = 65). ATIs were detected in 73% of the patients who did
not receive concomitant immunosuppressive compared with 46% of the patients
treated with MTX or AZA (P <0.001).
No difference in ATI formation was seen between the MTX and AZA groups. Patients
who did not receive immunosuppressive therapy had lower infliximab serum levels
4 weeks after an infliximab infusion than did patients who received
immunosuppressive treatments. These results demonstrated that immunosuppressive
therapy reduces ATI formation and improves the pharmacokinetics of infliximab.
In a related editorial, Hanauer notes that, until recently, infliximab had been
the only anti–tumor necrosis factor (TNF) agent available for the management
of CD and UC. To optimize its efficacy and long-term use, an induction and
maintenance regimen with concomitant immunosuppressive therapy had been
recommended. These recommendations are now coming under scrutiny due to the
increased risk of infections and neoplasia associated with the use of
immunosuppressants in conjunction with induction-maintenance anti-TNF therapy
and the expected availability of alternative biologic agents that appear to lack
cross-immunogenicity. Presently, either short-term (6- to 12-month) concomitant
therapy or biologic monotherapy appears to offer the best balance between short-
and long-term safety and efficacy for the treatment of patients with IBD. In
settings in which episodic therapy is (inappropriately) demanded by regulatory
or funding authorities, the benefit appears to favor concomitant therapy,
although the risks related to both disease progression and potential toxicities
exceed those related to monotherapy with an induction and maintenance regimen. (Vermeire
S, et al. Gut. 2007;56:1226–1231;
Hanauer
|
|
This web site is supported through educational
grants from Note: By clicking on the above logos you are leaving this educational site Comments or requests to unsubscribe can be e-mailed to
info@ibdwatch.com |
