1
|
Pasternak B. Medical management of pediatric inflammatory bowel disease. Semin Pediatr Surg 2024; 33:151398. [PMID: 38582057 DOI: 10.1016/j.sempedsurg.2024.151398] [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] [Indexed: 04/08/2024]
Abstract
Management of inflammatory bowel disease, both Crohn's disease (CD) and ulcerative colitis (UC), has seen a seismic shift over the past decade. Over the past five years, there has been the introduction of many new therapies with differing mechanisms of action and a goal of achieving mucosal healing, as well as clinical and biochemical remission (1,2). In addition, management is aimed at restoring normal growth and normalizing quality of life. The ultimate goal is to individualize medical management and determine the right drug for the right patient by identifying which inflammatory pathway is predominant and avoiding unwarranted lack of efficacy or side effects through biomarkers and risk prognostication. Patient's age, location of disease, behavior (inflammatory vs. penetrating/structuring), severity and growth delay all play into deciding on the best treatment approach. Ultimately, early intervention is key in preventing complications. The therapeutic approaches to management can be broken down to nutritional therapy, biologic agents, immunomodulators (including corticosteroids), aminosalicylates and antibiotics. There are numerous other therapies, such as small molecule agents recently approved in adults, which are garnering a great deal of interest.
Collapse
Affiliation(s)
- Brad Pasternak
- Division of Pediatric Gastroenterology, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona, USA.
| |
Collapse
|
2
|
Bolia R, Goel A, Semwal P, Srivastava A. Oral Tacrolimus in Steroid Refractory and Dependent Pediatric Ulcerative Colitis-A Systematic Review and Meta-Analysis. J Pediatr Gastroenterol Nutr 2023; 77:228-234. [PMID: 37184447 DOI: 10.1097/mpg.0000000000003827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND There are limited treatment options for children with steroid-refractory or dependent ulcerative colitis (UC). A few observational studies suggest efficacy of oral tacrolimus. We performed a systematic review and meta-analysis to assess the efficacy of tacrolimus in pediatric UC. METHODS PubMed and Scopus were searched for publications related to the use of oral tacrolimus in pediatric UC. Data regarding the clinical response and colectomy-free survival were extracted from studies that met the selection criteria. RESULTS The search strategy yielded 492 articles of which 7 studies were included in the final review. They included 166 children (111 steroid-refractory, 52 steroid-dependent, 3 no steroids). Majority of cases (150/166 [90%]) were naïve to biologics. An initial response to tacrolimus therapy was seen in 84% (95% CI: 73%-93%) (n = 7 studies). No difference was observed between children with high (>10 ng/mL) or low tacrolimus levels (127/150 [85%] vs 12/16 [75%], P = 0.3). No difference in initial response between the children who were steroid refractory or dependent (92/111 [83%] vs 46/52 [88%], P = 0.36). The response in the biologic-exposed group (n = 10) was 70%. At 1-year follow-up, 15.2% (95% CI: 7%-21%) (n = 2 studies, 85 patients) had a sustained response on only tacrolimus. The pooled frequency of 1-year colectomy-free survival in children treated with initial oral tacrolimus was 64% (95% CI: 53%-75%). Twelve (7.2%) patients required cessation of therapy because of side effects. CONCLUSION Tacrolimus has a high initial response in biologic naïve UC children. It can be effectively used as a bridge to other therapies with a 1-year colectomy-free survival of 64%.
Collapse
Affiliation(s)
- Rishi Bolia
- From the Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Akhil Goel
- the Department of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Pooja Semwal
- the Division of Paediatric Gastroenterology, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anshu Srivastava
- the Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
3
|
Zimmerman LA, Spaan J, Weinbren N, Manokaran K, Ajithkumar A, Bogursky A, Liu E, Lillehei C, Weil BR, Zalieckas JM, Bousvaros A, Rufo PA. Efficacy and Safety of Tacrolimus or Infliximab Therapy in Children and Young Adults With Acute Severe Colitis. J Pediatr Gastroenterol Nutr 2023; 77:222-227. [PMID: 37477885 DOI: 10.1097/mpg.0000000000003824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION One-third of children and young adults admitted for management of acute severe colitis (ASC) fail intravenous corticosteroids. Infliximab (IFX) or tacrolimus (TAC) is often used to prevent urgent colectomy in these patients. However, no prior studies have reviewed the outcome of pediatric patients with ASC who were treated with either IFX or TAC. METHODS We retrospectively identified 170 pediatric patients with ASC admitted to our institution who did not respond to intravenous corticosteroids and were subsequently treated with either IFX or TAC. We compared 6-month colectomy rates, time to colectomy, improvement in disease activity indices, and adverse effects. RESULTS The mean age of patients in the IFX (n = 84) and TAC (n = 86) groups were 14 and 13.8 years, respectively. The median study follow-up time was 23 months. The rate of colectomy 6 months from rescue therapy was similar whether patients received IFX or TAC (22.6% vs 26.7%, respectively, P = 0.53). The mean decline in Pediatric Ulcerative Colitis Activity Index scores from admission to discharge in those treated with IFX (31.9) or TAC (29.8) was similar (P = 0.63). Three patients treated with IFX experienced infusion reactions. Six patients treated with TAC experienced changes in renal function or electrolytes, and 4 patients reported neurologic symptoms. CONCLUSIONS There were no significant differences in the likelihood of colectomy 6 months after initiating IFX or TAC rescue therapy. Efficacy of both agents was comparable. The types of adverse effects differed by therapy. These data support the use of either TAC or IFX in children with ASC refractory to intravenous corticosteroids.
Collapse
Affiliation(s)
- Lori A Zimmerman
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Jonathan Spaan
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Nathan Weinbren
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Krishanth Manokaran
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Aravindh Ajithkumar
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Anna Bogursky
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Enju Liu
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Craig Lillehei
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Brent R Weil
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Jill M Zalieckas
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Athos Bousvaros
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Paul A Rufo
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| |
Collapse
|
4
|
Pharmacologic Management of Monogenic and Very Early Onset Inflammatory Bowel Diseases. Pharmaceutics 2023; 15:pharmaceutics15030969. [PMID: 36986830 PMCID: PMC10059893 DOI: 10.3390/pharmaceutics15030969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Inflammatory bowel disease (IBD) is treated with a variety of immunomodulating and immunosuppressive therapies; however, for the majority of cases, these therapies are not targeted for specific disease phenotypes. Monogenic IBD with causative genetic defect is the exception and represents a disease cohort where precision therapeutics can be applied. With the advent of rapid genetic sequencing platforms, these monogenic immunodeficiencies that cause inflammatory bowel disease are increasingly being identified. This subpopulation of IBD called very early onset inflammatory bowel disease (VEO-IBD) is defined by an age of onset of less than six years of age. Twenty percent of VEO-IBDs have an identifiable monogenic defect. The culprit genes are often involved in pro-inflammatory immune pathways, which represent potential avenues for targeted pharmacologic treatments. This review will provide an overview of the current state of disease-specific targeted therapies, as well as empiric treatment for undifferentiated causes of VEO-IBD.
Collapse
|
5
|
Lee WS, Arai K, Alex G, Treepongkaruna S, Kim KM, Choong CL, Mercado KS, Darma A, Srivastava A, Aw MM, Huang J, Ni YH, Malik R, Tanpowpong P, Tran HN, Ukarapol N. Medical Management of Pediatric Inflammatory Bowel Disease (PIBD) in the Asia Pacific Region: A Position Paper by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group. J Gastroenterol Hepatol 2022; 38:523-538. [PMID: 36574956 DOI: 10.1111/jgh.16097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/08/2022] [Accepted: 12/25/2022] [Indexed: 12/29/2022]
Abstract
Pediatric inflammatory bowel disease (PIBD) is rising rapidly in many industrialised and affluent areas in the Asia Pacific region. Current available guidelines, mainly from Europe and North America, may not be completely applicable to clinicians caring for children with PIBD in this region due to differences in disease characteristics and regional resources constraints. This position paper is an initiative from the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) with the aim of providing an up-to-date, evidence-based approach to PIBD in the Asia Pacific region, taking into consideration the unique disease characteristics and financial resources available in this region. A group of pediatric gastroenterologists with special interest in PIBD performed an extensive literature search covering epidemiology, disease characteristics and natural history, management and monitoring. Gastrointestinal infections, including tuberculosis, need to be excluded before diagnosing IBD. In some populations in Asia, the Nudix Hydrolase 15 (NUD15) gene is a better predictor of leukopenia induced by azathioprine than thiopurine-S-methyltransferase (TPMT). The main considerations in the use of biologics in the Asia Pacific region are high cost, ease of access, and potential infectious risk, especially tuberculosis. Conclusion: This position paper provides a useful guide to clinicians in the medical management of children with PIBD in the Asia Pacific region.
Collapse
Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - George Alex
- Department of Gastroenterology and Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Chee Liang Choong
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Karen Sc Mercado
- Makati Medical Center and The Medical City, Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition, Manila, Philippines
| | - Andy Darma
- Department of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Marion M Aw
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Huang
- Division of Paediatric Gastroenterology, Nutrition, Hepatology and Liver Transplantation, Department of Paediatrics, National University Hospital, Singapore
| | - Yen Hsuan Ni
- National Taiwan University College of Medicine, Taiwan
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Pornthep Tanpowpong
- Department of Pediatrics, Faculty of Medicine Ramathibodi, Mahidol University, Bangkok, Thailand
| | - Hong Ngoc Tran
- Department of Gastroenterology, Children's Hospital # 1, Ho Chi Minh City, Vietnam
| | - Nuthapong Ukarapol
- Department of Pediatric Gastroenterology and Hepatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
6
|
Yanagi T, Ushijima K, Koga H, Tomomasa T, Tajiri H, Kunisaki R, Isihige T, Yamada H, Arai K, Yoden A, Aomatsu T, Nagata S, Uchida K, Ohtsuka Y, Shimizu T. Tacrolimus for ulcerative colitis in children: a multicenter survey in Japan. Intest Res 2019; 17:476-485. [PMID: 31454858 PMCID: PMC6821948 DOI: 10.5217/ir.2019.00027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/15/2019] [Indexed: 01/15/2023] Open
Abstract
Background/Aims Tacrolimus is effective for refractory ulcerative colitis in adults, while data for children is sparse. We aimed to evaluate the effectiveness and safety of tacrolimus for induction and maintenance therapy in Japanese children with ulcerative colitis. Methods We retrospectively reviewed the multicenter survey data of 67 patients with ulcerative colitis aged < 17 years treated with tacrolimus between 2000 and 2012. Patients’ characteristics, disease activity, Pediatric Ulcerative Colitis Activity Index (PUCAI) score, initial oral tacrolimus dose, short-term (2-week) and long-term (1-year) outcomes, steroid-sparing effects, and adverse events were evaluated. Clinical remission was defined as a PUCAI score < 10; treatment response was defined as a PUCAI score reduction of ≥ 20 points compared with baseline. Results Patients included 35 boys and 32 girls (median [interquartile range] at admission: 13 [11–15] years). Thirty-nine patients were steroid-dependent and 26 were steroidrefractory; 20 had severe colitis and 43 had moderate colitis. The initial tacrolimus dose was 0.09 mg/kg/day (range, 0.05–0.12 mg/kg/day). The short-term clinical remission rate was 47.8%, and the clinical response rate was 37.3%. The mean prednisolone dose was reduced from 19.2 mg/day at tacrolimus initiation to 5.7 mg/day at week 8 (P< 0.001). The adverse event rate was 53.7%; 6 patients required discontinuation of tacrolimus therapy. Conclusions Tacrolimus was a safe and effective second-line induction therapy for steroid-dependent and steroid-refractory ulcerative colitis in Japanese children.
Collapse
Affiliation(s)
- Tadahiro Yanagi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan.,Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan
| | - Kosuke Ushijima
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan.,Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan
| | - Hidenobu Koga
- Clinical Research Support Office, Aso Iizuka Hospital, Iizuka, Japan
| | - Takeshi Tomomasa
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,PAL Children's Clinic, Isesaki, Japan
| | - Hitoshi Tajiri
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics, Osaka General Medical Center, Osaka, Japan
| | - Reiko Kunisaki
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Inflammatory Bowel Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Takashi Isihige
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroyuki Yamada
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsuhiro Arai
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsushi Yoden
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - Tomoki Aomatsu
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - Satoru Nagata
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Keiichi Uchida
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoshikazu Ohtsuka
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group, Japan.,Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
7
|
Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019; 41:261-307. [DOI: 10.1097/ftd.0000000000000640] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
8
|
Brunet M, van Gelder T, Åsberg A, Haufroid V, Hesselink DA, Langman L, Lemaitre F, Marquet P, Seger C, Shipkova M, Vinks A, Wallemacq P, Wieland E, Woillard JB, Barten MJ, Budde K, Colom H, Dieterlen MT, Elens L, Johnson-Davis KL, Kunicki PK, MacPhee I, Masuda S, Mathew BS, Millán O, Mizuno T, Moes DJAR, Monchaud C, Noceti O, Pawinski T, Picard N, van Schaik R, Sommerer C, Vethe NT, de Winter B, Christians U, Bergan S. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019. [DOI: 10.1097/ftd.0000000000000640
expr 845143713 + 809233716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
|
9
|
Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol 2019; 114:384-413. [PMID: 30840605 DOI: 10.14309/ajg.0000000000000152] [Citation(s) in RCA: 783] [Impact Index Per Article: 156.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ulcerative colitis (UC) is an idiopathic inflammatory disorder. These guidelines indicate the preferred approach to the management of adults with UC and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process. In instances where the evidence was not appropriate for GRADE, but there was consensus of significant clinical merit, "key concept" statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not only, approach to clinical scenarios.
Collapse
Affiliation(s)
- David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Crohn's and Colitis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Bryan G Sauer
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
10
|
Whaley KG, Rosen MJ. Contemporary Medical Management of Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2019; 25:56-66. [PMID: 29889235 PMCID: PMC6290785 DOI: 10.1093/ibd/izy208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Indexed: 02/07/2023]
Abstract
Acute severe ulcerative colitis is a medical emergency that requires prompt recognition, evaluation, and intervention. Patients require hospital admission with laboratory, radiographic, and endoscopic evaluation with initiation of corticosteroid treatment. Despite early intervention, many patients require salvage medical therapy, with some progressing to colectomy. Here we review important concepts and recent advances in the evaluation and medical management of adult and pediatric patients with acute severe ulcerative colitis.
Collapse
Affiliation(s)
- Kaitlin G Whaley
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael J Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
11
|
Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos KH, Croft N, Navas-López VM, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 2: Acute Severe Colitis-An Evidence-based Consensus Guideline From the European Crohn's and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:292-310. [PMID: 30044358 DOI: 10.1097/mpg.0000000000002036] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Acute severe colitis (ASC) is one of the few emergencies in pediatric gastroenterology. Tight monitoring and timely medical and surgical interventions may improve outcomes and minimize morbidity and mortality. We aimed to standardize daily treatment of ASC in children through detailed recommendations and practice points which are based on a systematic review of the literature and consensus of experts. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Fifteen predefined questions were addressed by working subgroups. An iterative consensus process, including 2 face-to-face meetings, was followed by voting of the national representatives of ECCO and all members of the Paediatric Inflammatory Bowel Disease (IBD) Porto group of ESPGHAN (43 voting experts). RESULTS A total of 24 recommendations and 43 practice points were endorsed with a consensus rate of at least 91% regarding diagnosis, monitoring, and management of ASC in children. A summary flowchart is presented based on daily scoring of the Paediatric Ulcerative Colitis Activity Index. Several topics have been altered since the previous 2011 guidelines and from those published in adults. DISCUSSION These guidelines standardize the management of ASC in children in an attempt to optimize outcomes of this intensive clinical scenario.
Collapse
Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- Ist Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva (affiliated to the Sackler Faculty of Medicine), Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | | | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver BC, Canada
| | | |
Collapse
|
12
|
Cabrera JM, Sato TT. Medical and Surgical Management of Pediatric Ulcerative Colitis. Clin Colon Rectal Surg 2018; 31:71-79. [PMID: 29487489 PMCID: PMC5825852 DOI: 10.1055/s-0037-1609021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Inflammatory bowel disease (IBD) describes a spectrum of idiopathic, lifelong, and progressive intestinal inflammatory conditions that includes Crohn's disease, ulcerative colitis, and indeterminate colitis. A worldwide increase in the incidence of IBD has been observed. In comparison to adults, IBD occurring during childhood and adolescence has several unique clinical characteristics and surgical management issues. In this article, we provide an overview contrasting these important differences.
Collapse
Affiliation(s)
- José M. Cabrera
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Thomas T. Sato
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Children's Corporate Center, Milwaukee, Wisconsin
| |
Collapse
|
13
|
Tacrolimus Exerts Only a Transient Effectiveness in Refractory Pediatric Crohn Disease: A Case Series. J Pediatr Gastroenterol Nutr 2017; 64:721-725. [PMID: 27429426 DOI: 10.1097/mpg.0000000000001338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Tacrolimus is an immunosuppressive agent that has been proposed in the treatment of severe ulcerative colitis. The present study examined the effectiveness and safety of tacrolimus in treating refractory Crohn disease (CD) colitis in children. METHODS All children treated by oral tacrolimus for CD colitis at a tertiary pediatric center were included in the study. All patients were refractory to steroids and infliximab. Clinical response (decreased pediatric CD activity index [PCDAI] >15 and PCDAI <30) and remission (PCDAI <10) were monitored at 2, 4, 6, 12, and 24 months after induction. Tacrolimus blood levels and adverse effects were also noted. RESULTS Among 220 patients with CD, 8 children (including 3 girls, median age 14 [9.5-18] years) were registered with a median PCDAI of 58.7 (32.5-65) before tacrolimus initiation. In patients treated with tacrolimus, the overall clinical response rates were 6/8, 3/8, 2/8, 2/8, and 1/8 with a remission rate of 4/8, 0/8, 0/8, 2/8, and 0/8 at 2, 4, 6, 12, and 24 months, respectively. At 2 months, the PCDAI scores were lower than those at induction (median 11.2; P = 0.004) with the mean whole plasma level of tacrolimus being 8.75 ng/mL (5.9-10 ng/mL). Adverse events occurred in 6 of 8 patients, including renal dysfunction, insulin-dependent diabetes, paresthesia, and tremor. Tacrolimus interruption was required in 2 cases. CONCLUSIONS Tacrolimus could be considered to transiently treat refractory CD colitis. Tacrolimus could be used as a "bridge" toward another medical option in pediatric CD, although its adverse events are frequent.
Collapse
|
14
|
Hosoi K, Arai K, Matsuoka K, Shimizu H, Kamei K, Nakazawa A, Shimizu T, Tang J, Ito S. Prolonged tacrolimus for pediatric gastrointestinal disorder: Double-edged sword? Pediatr Int 2017; 59:588-592. [PMID: 27935231 DOI: 10.1111/ped.13211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 10/17/2016] [Accepted: 11/09/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although tacrolimus (TAC) can induce remission in children with refractory inflammatory bowel disease (IBD) or autoimmune gastroenteropathy (AGE), its use in maintenance therapy remains controversial. The aim of this study was to investigate the potential nephrotoxic nature of prolonged TAC use. METHODS This retrospective study reviewed children with gastrointestinal disorder who underwent kidney biopsy for the evaluation of renal damage during TAC therapy for >1 year. The clinical and histological features of renal damage were evaluated in this single-institution cohort. RESULTS Eighteen of 121 children with IBD and two children with AGE followed at a national children hospital in Tokyo, Japan, received TAC between August 2006 and April 2013. Among them, five (Crohn's disease, n = 3; autoimmune gastropathy, n = 1; autoimmune enteropathy, n = 1) received TAC for >1 year, and underwent kidney biopsy. All five had achieved remission on TAC, but had histological evidence of chronic nephrotoxicity. Renal damage in one patient with relatively low TAC trough level remained mild. Estimated glomerular filtration rate (eGFR) at the time of kidney biopsy was lower than at the initiation of TAC in all four available patients. Among them, eGFR improved in one patient after the decrease or discontinuation of TAC. CONCLUSIONS TAC appeared to be effective in children with refractory gastrointestinal disorder, but long-term use seems to cause irreversible renal damage. Rigorous monitoring of eGFR and kidney biopsy in selected cases should be considered for the proper adjustment of TAC.
Collapse
Affiliation(s)
- Kenji Hosoi
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Matsuoka
- Department of Diagnostic Pathology, National Center for Child Health and Development, Tokyo, Japan.,Department of Clinical Laboratory Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hirotaka Shimizu
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Nakazawa
- Department of Diagnostic Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Julian Tang
- Department of Education for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Yokohama City University, Kanagawa, Japan
| |
Collapse
|
15
|
Abstract
The prevalence of extraintestinal manifestations in inflammatory bowel diseases varies from 6% to 46%. The aetiology of extraintestinal manifestations remains unclear. There are theories based on an immunological response influenced by genetic factors. Extraintestinal manifestations can involve almost every organ system. They may originate from the same pathophysiological mechanism of intestinal disease, or as secondary complications of inflammatory bowel diseases, or autoimmune diseases susceptibility. The most frequently involved organs are the joints, skin, eyes, liver and biliary tract. Renal involvement has been considered as an extraintestinal manifestation and has been described in both Crohn's disease and ulcerative colitis. The most frequent renal involvements in patients with inflammatory bowel disease are nephrolithiasis, tubulointerstitial nephritis, glomerulonephritis and amyloidosis. The aim of this review is to evaluate and report the most important data in the literature on renal involvement in patients with inflammatory bowel disease. Bibliographical searches were performed of the MEDLINE electronic database from January 1998 to January 2015 with the following key words (all fields): (inflammatory bowel disease OR Crohn's disease OR ulcerative colitis) AND (kidney OR renal OR nephrotoxicity OR renal function OR kidney disease OR renal disease OR glomerulonephritis OR interstitial nephritis OR amyloidosis OR kidney failure OR renal failure) AND (5-aminosalicylic acid OR aminosalicylate OR mesalazine OR TNF-α inhibitors OR cyclosporine OR azathioprine OR drugs OR pediatric).
Collapse
Affiliation(s)
- Domenico Corica
- Department of Pediatrics, University of Messina, Messina, Italy
| | - Claudio Romano
- Department of Pediatrics, University of Messina, Messina, Italy
| |
Collapse
|
16
|
Rodríguez-Lago I, Merino O, Nantes Ó, Muñoz C, Aguirre U, Cabriada JL. Previous exposure to biologics and C-reactive protein are associated with the response to tacrolimus in inflammatory bowel disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:550-7. [DOI: 10.17235/reed.2016.4447/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
17
|
Matsuoka K, Saito E, Fujii T, Takenaka K, Kimura M, Nagahori M, Ohtsuka K, Watanabe M. Tacrolimus for the Treatment of Ulcerative Colitis. Intest Res 2015; 13:219-26. [PMID: 26130996 PMCID: PMC4479736 DOI: 10.5217/ir.2015.13.3.219] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 02/07/2023] Open
Abstract
Tacrolimus is a calcineurin inhibitor used for the treatment of corticosteroid-refractory ulcerative colitis (UC). Two randomized controlled trials and a number of retrospective studies have assessed the therapeutic effect of tacrolimus in UC patients. These studies showed that tacrolimus has excellent short-term efficacy in corticosteroid-refractory patients, with the rates of clinical response ranging from 61% to 96%. However, the long-term prognosis of patients treated with tacrolimus is disappointing, and almost 50% of patients eventually underwent colectomy in long-term follow-up. Tacrolimus can achieve mucosal healing in 40-50% of patients, and this is associated with a favorable long-term prognosis. Anti-tumor necrosis factor (TNF)-α antibodies are another therapeutic option in corticosteroid-refractory patients. A prospective head-to-head comparative study of tacrolimus and infliximab is currently being performed to determine which treatment is more effective in corticosteroid-refractory patients. Several retrospective studies have demonstrated that switching between tacrolimus and anti-TNF-α antibody therapy was effective in patients who were refractory to one of the treatments. Most adverse events of tacrolimus are mild; however, opportunistic infections, especially pneumocystis pneumonia, are the most important adverse events, and these should be carefully considered during treatment. Several issues on tacrolimus treatment in UC patients remain unsolved (e.g., use of tacrolimus as remission maintenance therapy). Further controlled studies are needed to optimize the use of tacrolimus for the treatment of UC.
Collapse
Affiliation(s)
- Katsuyoshi Matsuoka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiko Saito
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Maiko Kimura
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
18
|
Rosen MJ, Minar P, Vinks AA. Review article: applying pharmacokinetics to optimise dosing of anti-TNF biologics in acute severe ulcerative colitis. Aliment Pharmacol Ther 2015; 41:1094-103. [PMID: 25809869 PMCID: PMC4498660 DOI: 10.1111/apt.13175] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/05/2015] [Accepted: 03/04/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC), the most aggressive presentation of ulcerative colitis (UC), occurs in 15% of adults and children with UC. First line therapy with intravenous corticosteroids is ineffective in half of adults and one-third of children. Therapeutic monoclonal antibodies against TNF (anti-TNF therapy) are emerging as a common treatment for ASUC due to their similar efficacy to calcineurin inhibitors and more favourable adverse effect profile. AIM To comprehensively review the evidence for anti-TNF therapy for ASUC in children and adults with regard to outcomes and pharmacokinetics. METHODS PubMed and recent conference proceedings were searched using the terms 'ulcerative colitis', 'acute severe ulcerative colitis', 'anti-TNF', 'pharmacokinetics' and the generic names of specific anti-TNF agents. RESULTS Outcomes after anti-TNF therapy for ASUC remain suboptimal with about one half of children and adults undergoing colectomy. While several randomised controlled trials have demonstrated the efficacy of anti-TNF therapy for ambulatory patients with moderate to severely active UC, patients in these studies were less ill than those with ASUC. Patients with ASUC may exhibit more rapid clearance of anti-TNF biologics due to pharmacokinetic mechanisms influenced by disease severity. CONCLUSIONS Conventional weight-based dosing effective in patients with moderately to severely active UC, may not be equally effective in those with acute severe ulcerative colitis. Personalised anti-TNF dosing strategies, which integrate patient factors and early measures of pharmacokinetics and response, hold promise for ensuring sustained drug exposure and maximising early mucosal healing in patients with acute severe ulcerative colitis.
Collapse
Affiliation(s)
- M J Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | |
Collapse
|
19
|
Tacrolimus induction followed by maintenance monotherapy is useful in selected patients with moderate-to-severe ulcerative colitis refractory to prior treatment. Dig Liver Dis 2014; 46:875-80. [PMID: 25023007 DOI: 10.1016/j.dld.2014.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 05/02/2014] [Accepted: 06/13/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tacrolimus in refractory ulcerative colitis often serves as a bridge to long-term maintenance therapy with thiopurines. Our aim was to review efficacy and safety of tacrolimus in active ulcerative colitis resistant to conventional therapies, including anti-tumour necrosis factor. METHODS Charts of consecutive outpatients with refractory ulcerative colitis, in whom tacrolimus was orally administered as a 12 week-induction (target trough levels 10-15ng/mL) followed by a maintenance therapy (target trough levels 5-10ng/mL), were retrospectively reviewed. Clinical remission and response at weeks 4, 12 and 52 as well as adverse events within 1-year therapy were reported. RESULTS Twelve (40%) and six (20%) of the 30 patients included (14 males, mean age 37.1±1.4 years) achieved a clinical remission and response, respectively, at week 12. Three responders to tacrolimus initiation experienced drug-related adverse events requiring discontinuation. Among the 18 remaining initial responders who tolerated tacrolimus, 8 (27%) were in clinical remission at week 52, whereas the remainder either experienced adverse events requiring drug withdrawal (n=4) or relapsed (n=6). Overall adverse events were recorded in 14 patients (46%), mainly finger tremor and urinary infections. CONCLUSION Oral monotherapy with tacrolimus may be a valuable long-term therapeutic option in selected patients with moderate-to-severe active refractory ulcerative colitis.
Collapse
|
20
|
Lawrance IC. What is left when anti-tumour necrosis factor therapy in inflammatory bowel diseases fails? World J Gastroenterol 2014; 20:1248-1258. [PMID: 24574799 PMCID: PMC3921507 DOI: 10.3748/wjg.v20.i5.1248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/05/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
The inflammatory bowel diseases (IBDs) are chronic incurable conditions that primarily present in young patients. Being incurable, the IBDs may be part of the patient’s life for many years and these conditions require therapies that will be effective over the long-term. Surgery in Crohn’s disease does not cure the disease with endoscopic recurrent in up to 70% of patients 1 year post resection. This means that, the patient will require many years of medications and the goal of the treating physician is to induce and maintain long-term remission without side effects. The development of the anti-tumour necrosis factor alpha (TNFα) agents has been a magnificent clinical advance in IBD, but they are not always effective, with loss of response overtime and, at times, discontinuation is required secondary to side effects. So what options are available if of the anti-TNFα agents can no longer be used? This review aims to provide other options for the physician, to remind them of the older established medications like azathioprine/6-mercaptopurine and methotrexate, the less established medications like mycophenolate mofetil and tacrolimus as well as newer therapeutic options like the anti-integins, which block the trafficking of leukocytes into the intestinal mucosa. The location of the intestinal inflammation must also be considered, as topical therapeutic agents may also be worthwhile to consider in the long-term management of the more challenging IBD patient. The more options that are available the more likely the patient will be able to have tailored therapy to treat their disease and a better long-term outcome.
Collapse
|
21
|
Abstract
IBD includes two classic entities, Crohn's disease and ulcerative colitis, and a third undetermined form (IBD-U), characterized by a chronic relapsing course resulting in a high rate of morbidity and impaired quality of life. Children with IBD are vulnerable in terms of growth failure, malnutrition and emotional effects. The aims of therapy have now transitioned from symptomatic control to the achievement of mucosal healing and deep remission. This type of therapy has been made possible by the advent of disease-modifying drugs, such as biologic agents, which are capable of interrupting the inflammatory cascade underlying IBD. Biologic agents are generally administered in patients who are refractory to conventional therapies. However, there is growing support that such agents could be used in the initial phases of the disease, typically in paediatric patients, to interrupt and cease the inflammatory process. Until several years ago, most therapeutic programmes in paediatric patients with IBD were borrowed from adult trials, whereas paediatric studies were often retrospective and uncontrolled. However, guidelines on therapeutic management of paediatric IBD and controlled, prospective, randomized trials including children with IBD have now been published. Here, the current knowledge concerning treatment options for children with IBD are reported. We also highlight the effectiveness and safety of new therapeutic advances in these paediatric patients.
Collapse
|
22
|
Abstract
Increasing numbers of adolescents are being diagnosed with Crohn's disease or ulcerative colitis, the two main subtypes of inflammatory bowel disease. These young people face many short- and long-term challenges; one or more medical therapies may be required indefinitely; their disease may have great impact, in terms of their schooling and social activities. However, the management of adolescents with one of these incurable conditions needs to encompass more than just medical therapies. Growth, pubertal development, schooling, transition, adherence, and psychological well-being are all important aspects. A multidisciplinary team setting, catering to these components of care, is required to ensure optimal outcomes in adolescents with inflammatory bowel disease.
Collapse
Affiliation(s)
- J Bishop
- Paediatric Gastroenterology, Starship Children’s Hospital, Auckland, New Zealand
| | - DA Lemberg
- Department of Gastroenterology, Sydney Children’s Hospital, Sydney, Australia
| | - AS Day
- Department of Paediatrics, University of Otago (Christchurch), Christchurch, New Zealand
| |
Collapse
|
23
|
Navas-López VM, Blasco Alonso J, Serrano Nieto MJ, Girón Fernández-Crehuet F, Argos Rodriguez MD, Sierra Salinas C. Oral tacrolimus for pediatric steroid-resistant ulcerative colitis. J Crohns Colitis 2014; 8:64-9. [PMID: 23582736 DOI: 10.1016/j.crohns.2013.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 03/12/2013] [Accepted: 03/13/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) occurring during childhood is generally extensive and is associated with severe flares that may require intravenous steroid treatment. In cases of corticosteroid resistance is necessary to introduce a second-line treatment to avoid or delay surgery. AIMS To describe the efficacy and safety of oral tacrolimus for the treatment of severe steroid-resistant UC. METHODS We performed a retrospective study that included all patients under age 18 suffering from severe steroid-resistant UC treated with oral tacrolimus during the period January 1998 to October 2012 and with a follow-up period after treatment of 24 months or more. RESULTS A total of ten patients were included. The age at baseline was 9.4±4.9 years, and the time from diagnosis was 1.3 months (IQR, 1-5.7). Seven of the patients were in their first flare of disease. All of them received an oral dose of 0.12 mg/kg/day of tacrolimus divided in two doses. Trough plasma levels of tacrolimus were maintained between 4 and 13 ng/ml. Response was seen in 5/10 patients at 12 months, colectomy was eventually performed in 60% of patients during the follow-up period. CONCLUSIONS Tacrolimus is useful in inducing remission in patients with severe steroid-resistant UC, preventing or delaying colectomy, and allowing the patient and family to prepare for a probable surgery. Tacrolimus may also be used as a treatment bridge for corticosteroid-dependent patients until the new maintenance therapy takes effect.
Collapse
Affiliation(s)
- V M Navas-López
- Pediatric Gastroentrology and Nutrition Unit, Hospital Materno Infantil, Málaga, Spain.
| | - J Blasco Alonso
- Pediatric Gastroentrology and Nutrition Unit, Hospital Materno Infantil, Málaga, Spain.
| | - M J Serrano Nieto
- Pediatric Gastroentrology and Nutrition Unit, Hospital Materno Infantil, Málaga, Spain.
| | | | - M D Argos Rodriguez
- Pediatric Gastroentrology and Nutrition Unit, Hospital Materno Infantil, Málaga, Spain.
| | - C Sierra Salinas
- Pediatric Gastroentrology and Nutrition Unit, Hospital Materno Infantil, Málaga, Spain.
| |
Collapse
|
24
|
Abstract
BACKGROUND Pouchitis is the most common complication after restorative proctocolectomy for ulcerative colitis, and it leads to pouch failure. The administration of oral antibiotics is the main treatment for pouchitis; however, in some cases, antibiotic-refractory pouchitis may develop, which requires further medical therapy. OBJECTIVE We investigated the applicability of topical tacrolimus for refractory pouchitis. DESIGN We performed a prospective pilot study. The study protocols were registered with the University Hospital Medical Information Network Clinical Trials Registry, 000006658. SETTING This study was conducted in the Surgical Department of Hyogo College of Medicine. PATIENTS Patients with antibiotic-refractory pouchitis were treated for 8 weeks with a tacrolimus enema. MAIN OUTCOME MEASURES The efficacy was assessed by comparing Pouchitis Disease Activity Index scores. Safety was assessed by measuring whole blood tacrolimus trough levels. RESULTS Ten patients with refractory pouchitis were enrolled. No severe adverse events occurred. The mean scores decreased from 15.9 ± 0.8 to 7.8 ± 0.8 during 8 weeks of treatment (p < 0.01). Specifically, the clinical symptom, endoscopic finding, and histological finding subscores decreased to 0.8 ± 0.6, 3.9 ± 0.2, and 2.9 ± 0.4. Nine patients recovered from their clinical symptoms, and 3 patients recovered from pouchitis. LIMITATIONS This small study was neither blinded nor randomized. CONCLUSIONS This study demonstrates that the use of topical tacrolimus for the treatment of refractory pouchitis is safe and effective in the short term for clinical symptoms. Although complete endoscopic healing was not achieved, this treatment may have early rescue efficacy in the treatment of antibiotic-refractory pouchitis.
Collapse
|
25
|
Gray FL, Turner CG, Zurakowski D, Bousvaros A, Linden BC, Shamberger RC, Lillehei CW. Predictive value of the Pediatric Ulcerative Colitis Activity Index in the surgical management of ulcerative colitis. J Pediatr Surg 2013; 48:1540-5. [PMID: 23895969 DOI: 10.1016/j.jpedsurg.2013.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 02/25/2013] [Accepted: 03/02/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE The primary purpose of this study was to investigate the relationship between Pediatric Ulcerative Colitis Activity Index (PUCAI) and operative management. We also specifically evaluated those patients receiving tacrolimus for their disease. METHODS A retrospective review (1/06-1/11) identified ulcerative colitis patients (≤21 years old) undergoing restorative proctocolectomy with rectal mucosectomy and ileal pouch-anal anastomosis. Main outcomes included pre-operative PUCAI, combined versus staged procedure, and postoperative complications. Patients receiving tacrolimus within 3 months of surgical intervention were identified. PUCAI at tacrolimus induction and medication side effects were also noted. RESULTS Sixty patients were identified. Forty-two (70%) underwent combined and 18 (30%) had staged procedures. Pre-operative PUCAI was lower for combined versus staged patients (p = < 0.001). Furthermore, a higher pre-operative PUCAI strongly correlated with the likelihood of undergoing a staged procedure (p < 0.001). Forty-four patients (73%) received tacrolimus. Significant improvement in their PUCAI was noted from induction to pre-operative evaluation (p < 0.001). Minor and reversible side effects occurred in 46% of patients receiving tacrolimus, but complication rates were not significantly different. CONCLUSIONS There is a very strong correlation between the PUCAI and the likelihood of undergoing a staged procedure. A significant improvement in PUCAI occurs following preoperative tacrolimus therapy.
Collapse
Affiliation(s)
- Fabienne L Gray
- Department of Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Patients with inflammatory bowel disease who are refractory to standard therapies frequently require surgery. The long-term efficacy of tacrolimus in patients who fail standard immunosuppressive and antitumor necrosis factor α therapy is unknown. METHODS Thirty-five patients (11 Crohn's disease and 24 ulcerative colitis) with medication-resistant disease were treated with oral tacrolimus and reviewed retrospectively. Patients were commenced on tacrolimus 0.1 mg/kg/day, with a trough level targeted between 8 and 12 ng/mL. Clinical response or remission at 30 days, 90 days, and 1 year was assessed. The overall risk of requiring surgery and predictive factors were also assessed. RESULTS All patients had failed a thiopurine, 5 (14%) had also failed methotrexate, while 90% had a primary or secondary nonresponse, or an incomplete response, to an antitumor necrosis factor α agent. The proportions that achieved a clinical response at 30 days, 90 days, and 1 year was 65.7%, 60%, and 31.4%, respectively, whereas the corresponding proportions in remission were 40%, 37.1%, and 22.9%. The cumulative risk of requiring surgery was 40.4% at 1 year and 59.3% at 2 years with a median time to surgery of 22 months (range, 0.5-84 months). Patients who were steroid refractory, or dependent, before starting tacrolimus were more likely to have surgery (P = 0.006), whereas patients who were able to achieve or maintain a clinical response with tacrolimus by 90 days were less likely (P = 0.004). CONCLUSIONS Tacrolimus is able to induce a clinical response in a third and remission in a fifth of medically refractory patients with inflammatory bowel disease at 1 year. A 90-day therapeutic trial is worthwhile in difficult to treat patients.
Collapse
|
27
|
Day AS, Ledder O, Leach ST, Lemberg DA. Crohn's and colitis in children and adolescents. World J Gastroenterol 2012; 18:5862-9. [PMID: 23139601 PMCID: PMC3491592 DOI: 10.3748/wjg.v18.i41.5862] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 07/02/2012] [Accepted: 07/09/2012] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease and ulcerative colitis can be grouped as the inflammatory bowel diseases (IBD). These conditions have become increasingly common in recent years, including in children and young people. Although much is known about aspects of the pathogenesis of these diseases, the precise aetiology is not yet understood, and there remains no cure. Recent data has illustrated the importance of a number of genes-several of these are important in the onset of IBD in early life, including in infancy. Pain, diarrhoea and weight loss are typical symptoms of paediatric Crohn's disease whereas bloody diarrhoea is more typical of colitis in children. However, atypical symptoms may occur in both conditions: these include isolated impairment of linear growth or presentation with extra-intestinal manifestations such as erythema nodosum. Growth and nutrition are commonly compromised at diagnosis in both Crohn's disease and colitis. Consideration of possible IBD and completion of appropriate investigations are essential to ensure prompt diagnosis, thereby avoiding the consequences of diagnostic delay. Patterns of disease including location and progression of IBD in childhood differ substantially from adult-onset disease. Various treatment options are available for children and adolescents with IBD. Exclusive enteral nutrition plays a central role in the induction of remission of active Crohn's disease. Medical and surgical therapies need to considered within the context of a growing and developing child. The overall management of these chronic conditions in children should include multi-disciplinary expertise, with focus upon maintaining control of gut inflammation, optimising nutrition, growth and quality of life, whilst preventing disease or treatment-related complications.
Collapse
|
28
|
Turner D, Travis SPL, Griffiths AM, Ruemmele FM, Levine A, Benchimol EI, Dubinsky M, Alex G, Baldassano RN, Langer JC, Shamberger R, Hyams JS, Cucchiara S, Bousvaros A, Escher JC, Markowitz J, Wilson DC, van Assche G, Russell RK. Consensus for managing acute severe ulcerative colitis in children: a systematic review and joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN. Am J Gastroenterol 2011; 106:574-88. [PMID: 21224839 DOI: 10.1038/ajg.2010.481] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Acute severe ulcerative colitis (ASC) is a potentially life-threatening disease. We aimed to formulate guidelines for managing ASC in children based on systematic review of the literature and robust consensus process. This manuscript is a product of a joint effort of the ECCO (European Crohn's and Colitis Organization), the Pediatric Porto Inflammatory Bowel Disease (IBD) Working group of ESPGHAN (European Society of Pediatric Gastroenterology, Hepatology, and Nutrition) and ESPGHAN. METHODS A group of 19 experts in pediatric IBD participated in an iterative consensus process including two face-to-face meetings. A total of 17 predefined questions were addressed by working subgroups based on a systematic review of the literature. RESULTS The recommendations and practice points were eventually endorsed with a consensus rate of at least 95% regarding: definitions, initial evaluation, standard therapy, timing of second-line therapy, the role of endoscopic evaluation and heparin prophylaxis, how to administer second-line medical therapy, how to assess response, surgical considerations, and discharge recommendations. A management flowchart is presented based on daily scoring of the Pediatric Ulcerative Colitis Activity Index (PUCAI), along with 28 formal recommendations and 34 practice points. CONCLUSIONS These guidelines provide clinically useful points to guide the management of ASC in children. Taken together, the recommendations offer a standardized protocol that allows effective monitoring of disease progress and timely treatment escalation when needed.
Collapse
Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
ABCB1 single-nucleotide polymorphisms determine tacrolimus response in patients with ulcerative colitis. Clin Pharmacol Ther 2011; 89:422-8. [PMID: 21289623 DOI: 10.1038/clpt.2010.348] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tacrolimus (Tac) is effective in the treatment of steroid-refractory ulcerative colitis (UC); however, nonresponse and unpredictable side effects are major limitations. Because Tac response in patients who have undergone solid-organ transplantation has been associated with the presence of variants in CYP3A and ABCB1, we elucidated the contributions of CYP3A4*1B and CYP3A5*3 and of ABCB1 1236C>T, 2677G>T,A, and 3435C>T polymorphisms to Tac response in 89 patients with UC. Short-term remission and response were achieved in 61 and 14% of the patients, respectively, and were associated with colectomy-free survival. In a linear logistic regression model, patients with homozygous variants for one of the three ABCB1 alleles showed significantly higher short-term remission rates as compared with those of other genotypes. The effects held true after multivariate analysis including multiple comparisons and were more pronounced after correction for dose-adjusted Tac blood trough levels. We suggest that ABCB1, but not CYP3A5, may predict short-term remission of Tac in steroid-refractory UC.
Collapse
|
30
|
Zitomersky NL, Verhave M, Trenor CC. Thrombosis and inflammatory bowel disease: a call for improved awareness and prevention. Inflamm Bowel Dis 2011; 17:458-70. [PMID: 20848518 DOI: 10.1002/ibd.21334] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic complications in patients with inflammatory bowel disease (IBD) are common and require improved awareness and prevention. In this review the interface between IBD and thrombosis is discussed, with emphasis on risk assessment and data to aid clinical decision making. Thromboembolic complications are 3-fold more likely in IBD patients than controls and the relative risk exceeds 15 during disease flares. Improved assessment of thrombosis risk for an individual patient includes thorough personal and family history and awareness of prothrombotic medications and lifestyle choices. Patients with the highest risk of thrombosis are those with active colonic disease, personal or strong family history of thrombosis, and those with significant acquired risk factors. Combined risk factors or hospitalization should prompt mechanical thromboprophylaxis. Indications for prophylactic anticoagulation are not defined currently by clinical studies, especially in pediatric patients, although some groups now advocate prophylactic anticoagulation for all hospitalized IBD patients and even some outpatients with disease flares. Thrombosis management requires a multidisciplinary therapeutic approach to balance anticoagulation and bleeding risk. While bleeding may occur with anticoagulation in IBD, data and experience indicate that therapeutic heparin is safe and bleeding manifestations can be managed supportively in most patients. Until prospective trials of prophylactic anticoagulation are published, management of thrombotic risk and prophylaxis in IBD will remain a clinical challenge.
Collapse
Affiliation(s)
- Naamah L Zitomersky
- Division of Gastroenterology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | | | | |
Collapse
|
31
|
Abstract
Pediatric ulcerative colitis (UC) has a more severe phenotype, reflected by more extensive disease and a higher rate of acute severe exacerbations. The pooled steroid-failure rate among 291 children from five studies is 34% (95% confidence interval [CI]: 27%-41%). It is suggested that corticosteroids should be dosed between 1-1.5 mg/kg up to 40-60 mg daily. Food restriction has a limited role in severe UC and should be generally discouraged in children who do not have a surgical abdomen. Appraisal of radiologic findings in children must recognize the variation in colonic width with age and size. Data suggest that the Pediatric UC Activity Index (PUCAI), determined at day 3, should be used to screen for patients likely to fail corticosteroids (>45 points), and at day 5 to dictate the introduction of second-line therapy (>65-70 points). Cyclosporine is successful in children with severe colitis but its use should be restricted to 3-4 months while bridging to thiopurine treatment (pooled short-term success rate 81% [95% CI: 76%-86%]; n = 94 from eight studies). Infliximab may be as effective as cyclosporine (75% pooled short-term response (95% CI: 67%-83%); n = 126, six studies) with a pooled 1-year response of 64% (95% CI: 56%-72%). In toxic megacolon, in patients refractory to one salvage medical therapy, and in chronic severe disease, colectomy may be preferred. Decision-making regarding colectomy in children must consider the toxicity of medication consumed over many future years, the quality of life and self-image associated with either choice, as well as both functional outcomes and, in females, fertility following pouch procedures.
Collapse
Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
| | | |
Collapse
|
32
|
Watson S, Pensabene L, Mitchell P, Bousvaros A. Outcomes and adverse events in children and young adults undergoing tacrolimus therapy for steroid-refractory colitis. Inflamm Bowel Dis 2011; 17:22-9. [PMID: 20722055 DOI: 10.1002/ibd.21418] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 06/07/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND Children with severe corticosteroid-resistant ulcerative colitis either need to undergo surgery or be treated with more intensive immunosuppression. Our aim was to characterize the short- and long-term outcomes and adverse events associated with the use of tacrolimus in a steroid-refractory pediatric population. METHODS We retrospectively reviewed the medical records of 46 children with steroid-refractory colitis treated with tacrolimus at Children's Hospital Boston between 1994 and 2008. Oral tacrolimus was initiated at a dose of 0.1 mg/kg twice a day and titrated to yield trough levels of 10-15 ng/mL for induction, and 5-10 ng/mL once in remission. The Pediatric Ulcerative Colitis Activity Index (PUCAI) and other measures of disease activity, adverse events, and long-term outcomes were assessed. Statistical analysis of outcomes was performed using SAS statistical software. RESULTS Ninety-three percent of patients were discharged without undergoing surgery. The median length of stay after starting tacrolimus was 10 days (range 4-37 days). The mean PUCAI score was 68 ± 13 prior to initiating tacrolimus, and 27 ± 18 at the time of hospital discharge. The probability of avoiding colectomy after starting tacrolimus was 40% at 26 months. The most common adverse events included hypertension (52%) and tremor (44%). There was one seizure and no deaths. CONCLUSIONS Tacrolimus is useful as induction therapy in pediatric patients with corticosteroid-refractory colitis and side effects are generally mild and reversible. Despite these findings, many patients develop exacerbations of colitis upon transition to maintenance therapies. The long-term colectomy rate in this challenging population remains ≈60% over time.
Collapse
Affiliation(s)
- Sheree Watson
- Division of Gastroenterology, Children's Hospital, Boston Massachusetts, USA
| | | | | | | |
Collapse
|
33
|
Bousvaros A. Use of immunomodulators and biologic therapies in children with inflammatory bowel disease. Expert Rev Clin Immunol 2010; 6:659-666. [DOI: 10.1586/eci.10.46] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
34
|
Abstract
OBJECTIVES Infliximab is effective in treating moderate/severe ulcerative colitis (UC) in adults. The aim of this study was to determine the outcome after treatment with infliximab in pediatric UC. METHODS We performed a multicenter cohort study of 332 pediatric patients with UC enrolled in the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry. Children<or=16 years of age and newly diagnosed with UC are enrolled in the registry. Disease and medication information are collected prospectively from the treating physician at diagnosis, 30 days, and quarterly thereafter. No interventions were specified, per protocol. RESULTS Of 332 patients, 52 (16%) received infliximab (23%<3 months from diagnosis, 38% 3-12 months, 38% >12 months). Mean age at infliximab initiation was 13.3+/-2.6 (range 6-17) years; 87% of patients had pancolitis. Median follow-up was 30 months. Continuous maintenance (CM) therapy was given in 65%, episodic in 21%, episodic converted to CM in 6%, and insufficient data in 8% of patients. Sixty-three percent of patients were corticosteroid refractory, and 35% were corticosteroid dependent. Concomitant medications at first infliximab infusion included corticosteroids (87%), thiopurines (63%), and 5-aminosalicylates (51%). Corticosteroid-free inactive disease by physician global assessment was noted in 12/44 (27%), 15/39 (38%), and 6/28 (21%) patients at 6, 12, and 24 months, respectively. Kaplan-Meier analysis showed that the likelihood of remaining colectomy free after treatment with infliximab was 75% at 6 months, 72% at 12 months, and 61% at 2 years. CONCLUSIONS In this cohort of children with UC receiving infliximab, corticosteroid-free inactive disease was observed in 38 and 21% of patients at 12 and 24 months, respectively. By 24 months, 61% of patients had avoided colectomy.
Collapse
|
35
|
Romano C, Comito D, Famiani A, Fries W. Oral tacrolimus (FK 506) in refractory paediatric ulcerative colitis. Aliment Pharmacol Ther 2010; 31:676-7; author reply 677-8. [PMID: 20148798 DOI: 10.1111/j.1365-2036.2009.04213.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
36
|
van Lierop PPE, de Haar C, Lindenbergh-Kortleve DJ, Simons-Oosterhuis Y, van Rijt LS, Lambrecht BN, Escher JC, Samsom JN, Nieuwenhuis EES. T-cell regulation of neutrophil infiltrate at the early stages of a murine colitis model. Inflamm Bowel Dis 2010; 16:442-51. [PMID: 19714763 DOI: 10.1002/ibd.21073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND T-cells are a main target for antiinflammatory drugs in inflammatory bowel disease. As the innate immune system is also implicated in the pathogenesis of these diseases, T-cell suppressors may not only inhibit T-cell-dependent production of proinflammatory mediators but also affect innate immune cell function. Specifically, these drugs may impair innate immune cell recruitment and activation through inhibition of T-cells or act independent of T-cell modulation. We explored the extent of immune modulation by the T-cell inhibitor tacrolimus in a murine colitis model. METHODS We assessed the effects of tacrolimus on trinitro-benzene sulphonic acid (TNBS) colitis in wildtype and Rag2-deficient mice. The severity of colitis was assessed by means of histological scores and weight loss. We further characterized the inflammation using immunohistochemistry and by analysis of isolated intestinal leukocytes at various stages of disease. RESULTS Tacrolimus-treated wildtype mice were less sensitive to colitis and had fewer activated T-cells. Inhibition of T-cell function was associated with strongly diminished recruitment of infiltrating neutrophils in the colon at the early stages of this model. In agreement, immunohistochemistry demonstrated that tacrolimus inhibited production of the neutrophil chemoattractants CXCL1 and CXCL2. Rag2-deficient mice displayed an enhanced baseline level of lamina propria neutrophils that was moderately increased in TNBS colitis and remained unaffected by tacrolimus. CONCLUSIONS Both the innate and the adaptive mucosal immune system contribute to TNBS colitis. Tacrolimus suppresses colitis directly through inhibition of T-cell activation and by suppression of T-cell-mediated recruitment of neutrophils.
Collapse
Affiliation(s)
- Pieter P E van Lierop
- Department of Pediatrics, Division of Gastroenterology & Nutrition, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Systematic review of the evidence base for the medical treatment of paediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2010; 50 Suppl 1:S14-34. [PMID: 20081542 DOI: 10.1097/mpg.0b013e3181c92caa] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To systematically review the evidence base for the medical (pharmaceutical and nutritional) treatment of paediatric inflammatory bowel disease. METHODS Key clinical questions were formulated regarding different treatment modalities used in the treatment of paediatric (not adult-onset) IBD, in particular the induction and maintenance of remission in Crohn disease and ulcerative colitis. Electronic searches were performed from January 1966 to December 2006, using the electronic search strategy of the Cochrane IBD group. Details of papers were entered on a dedicated database, reviewed in abstract form, and disseminated in full for appraisal. Clinical guidelines were appraised using the AGREE instrument and all other relevant papers were appraised using Scottish Intercollegiate Guidelines Network methodology, with evidence levels given to all papers. RESULTS A total of 6285 papers were identified, of which 1255 involved children; these were entered on the database. After critical appraisal, only 103 publications met our criteria as evidence on medical treatment of paediatric IBD. We identified 3 clinical guidelines, 1 systematic review, and 16 randomised controlled trials; all were of variable quality, with none getting the highest methodological scores. CONCLUSIONS This is the first comprehensive review of the evidence base for the treatment of paediatric IBD, highlighting the paucity of trials of high methodological quality. As a result, the development of clinical guidelines for managing children and young people with IBD must be consensus based, informed by the best-available evidence from the paediatric literature and high-quality data from the adult IBD literature, together with the clinical expertise and multidisciplinary experience of paediatric IBD experts.
Collapse
|
38
|
van Dieren JM, Lambers MEH, Kuipers EJ, Samsom JN, van der Woude CJ, Nieuwenhuis EES. Local immune regulation of mucosal inflammation by tacrolimus. Dig Dis Sci 2010; 55:2514-9. [PMID: 19949865 PMCID: PMC2914281 DOI: 10.1007/s10620-009-1047-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 10/27/2009] [Indexed: 12/09/2022]
Abstract
PURPOSE Tacrolimus is a potent immunomodulator that is effective in the treatment of inflammatory bowel disease (IBD). However, potential toxicity and systemic effects with oral intake limit its use. Local tacrolimus treatment is effective in a subgroup of proctitis patients. This study aimed to evaluate whether colonic mucosal immune cells are susceptible to locally applied tacrolimus in vitro. Our in vivo studies aimed at evaluating whether local tacrolimus treatment in mice would bring about local immune suppression and to compare colonic and systemic tacrolimus levels after locally and systemically applied tacrolimus. RESULTS In vitro tacrolimus inhibited the activation of multiple cell types present in colonic tissue; lamina propria T cells, NKT cells, and both classical- and non- classical antigen presenting cells. However, the cytokine production of epithelial cells was not inhibited by tacrolimus at these concentrations. After rectal administration in mice, tacrolimus blood levels were comparable to those obtained by oral intake. However, rectally treated mice exhibited a 14-fold higher concentration of tacrolimus within their colonic tissue than orally treated mice. Moreover, rectally applied tacrolimus resulted in a local but not a systemic immune suppression in mice. CONCLUSIONS Tacrolimus inhibits activation of several pivotal immune cells of the intestinal mucosa. Murine studies indicate that colonic application of tacrolimus induces local rather than systemic immune suppression.
Collapse
Affiliation(s)
- Jolanda M. van Dieren
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands ,Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus MC, University Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
| | - Margaretha E. H. Lambers
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus MC, University Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
| | - Ernst J. Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Janneke N. Samsom
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus MC, University Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Edward E. S. Nieuwenhuis
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus MC, University Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
| |
Collapse
|
39
|
Eficacia y seguridad de tacrolimus oral para el tratamiento de la enfermedad inflamatoria intestinal pediátrica. An Pediatr (Barc) 2009; 70:519-25. [DOI: 10.1016/j.anpedi.2009.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 03/13/2009] [Accepted: 03/16/2009] [Indexed: 01/21/2023] Open
|
40
|
van Dieren JM, van Bodegraven AA, Kuipers EJ, Bakker EN, Poen AC, van Dekken H, Nieuwenhuis EES, van der Woude CJ. Local application of tacrolimus in distal colitis: feasible and safe. Inflamm Bowel Dis 2009; 15:193-8. [PMID: 18825773 DOI: 10.1002/ibd.20644] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tacrolimus is a potent immunomodulator that is effective in the systemic treatment of inflammatory bowel diseases (IBD). However, potential toxicity and systemic (side) effects after oral intake limit its use. We investigated the local applicability and safety of tacrolimus for distal colitis. METHODS Patients with refractory left-sided colitis or proctitis were treated for 4 weeks with a daily tacrolimus 2-4 mg enema or 2 mg suppository. Safety of local tacrolimus treatment was assessed by measurement of whole blood tacrolimus trough levels by monitoring liver and kidney function and blood glucose levels. Efficacy of treatment was assessed by comparing the disease activity index (DAI) in ulcerative colitis (UC) patients and endoscopic and histologic appearances before and after 4 weeks of treatment. RESULTS Nineteen patients with left-sided colitis (n = 7) or proctitis (n = 12) were treated. Two patients with left-sided colitis had Crohn's disease (CD), the other 17 patients had UC. None of the patients developed side effects. Blood trough levels of tacrolimus were too low to induce systemic immune suppression. Thirteen of 19 patients (3/5 left-sided UC, 0/2 left-sided CD, and 10/12 proctitis) showed clinical improvement of disease activity after 4 weeks of local tacrolimus treatment. Moreover, a significant improvement of histological appearance was observed in the suppository-treated group. CONCLUSIONS This study demonstrates that local colonic application of tacrolimus 2-4 mg daily in patients with refractory distal colitis is feasible, probably safe, and potentially efficacious, and therefore opens the need for a further, randomized trial.
Collapse
Affiliation(s)
- Jolanda M van Dieren
- Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Guthery SL, Dong L, Dean JM, Holubkov R. US estimates of hospitalized pediatric patients with ulcerative colitis: implications for multicenter clinical studies. Inflamm Bowel Dis 2008; 14:1253-8. [PMID: 18512244 DOI: 10.1002/ibd.20521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The optimal clinical management of children hospitalized with ulcerative colitis (UC) is evolving. There are limited data quantifying the number of pediatric patients with UC admitted to hospitals in the United States. We analyzed the Kids' Inpatient Database (KID, 2003), to estimate the distribution of hospitalized children with UC and estimate sample sizes available for clinical research. METHODS We limited our analysis to subjects age less than 18 years. We defined cases of UC as discharge records associated with an ICD-9 code of 556.0-556.9 in the first position. We defined colectomy as principal procedure code of 45.8. We generated weighted estimates for these analyses. To estimate the relationship between number of patients and number of hospitals necessary for clinical trials, we generated 1000 simulated datasets. RESULTS A total of 2311 UC cases were identified. The mean age at admission was 13.1 (standard error [SE] 0.1) years, and 9% (SE 0.9%) underwent colectomy during their hospitalization. 1008 UC cases were treated at high-volume hospitals; the majority of these children were treated at children's hospitals. Simulation studies suggest that approximately 5 high-volume hospitals would be necessary to generate sample sizes necessary for a pilot clinical trial of refractory UC. CONCLUSIONS Approximately half of all young patients hospitalized with UC in the US were treated at a limited number of high-volume hospitals, and approximately 5 such centers would be adequate for pilot clinical trials of hospitalized patients with refractory UC.
Collapse
Affiliation(s)
- Stephen L Guthery
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA.
| | | | | | | |
Collapse
|
42
|
Baumgart DC, Macdonald JK, Feagan B. Tacrolimus (FK506) for induction of remission in refractory ulcerative colitis. Cochrane Database Syst Rev 2008:CD007216. [PMID: 18646177 DOI: 10.1002/14651858.cd007216] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND There are a limited number of treatment options for patients with refractory ulcerative colitis. Animal models of inflammatory bowel disease and uncontrolled studies in humans suggest that tacrolimus may be effective treatment for ulcerative colitis. OBJECTIVES This review aims to evaluate the efficacy of tacrolimus for induction of remission in patients with corticosteroid refractory ulcerative colitis. SEARCH STRATEGY MEDLINE (PubMed), The Cochrane Central Register of Controlled Trials, the IBD/FBD review group specialized register and the ISI-Research Institute were searched (January 1997 to November 2007) to identify relevant studies all randomized trials. SELECTION CRITERIA Each author independently reviewed potentially relevant studies to determine eligibility based on the pre-specified criteria. DATA COLLECTION AND ANALYSIS A data extraction form was developed and used to extract data from included studies. Two authors independently extracted data. Data were analyzed using Review Manager (RevMan 4.2.9). The primary outcomes were induction of remission and clinical improvement, as defined by the studies and expressed as a percentage of the patients randomized (intention to treat analysis). MAIN RESULTS One randomized controlled trial comparing high target serum concentration and low target serum concentration tacrolimus versus placebo was identified and included in the review. Clinical remission was observed in 19% (4/21) of patients in the high target serum concentration group, in 9% (2/22) in the low target serum concentration group and in 5% (1/20) in the placebo group (OR 2.27; 95% CI 0.35 to 14.75). A statistically significant benefit for clinical improvement at two weeks was observed. Clinical improvement was observed in 62% (13/21) of patients in the high target serum concentration group, in 36% (8/22) in the low target serum concentration group and in 10% (2/20) in the placebo group (OR 8.66; 95% CI 1.79 to 42.00; RD 0.39; 95% CI 0.20 to 0.59; NNT = 3). Patients in the high serum target concentration group were significantly more likely than placebo patients to experience adverse events related to treatment (P = 0.043). Finger tremor (n = 6) was the most common adverse event in the tacrolimus group. Other adverse events included: gastroenteritis, sepsis, sleepiness, hot flush, headache, queasiness and stomach discomfort. AUTHORS' CONCLUSIONS Tacrolimus may be effective for short-term clinical improvement in patients with refractory ulcerative colitis. However, these results should be interpreted with caution due to the small number of patients enrolled in the trial and other study limitations. Insufficient treatment and follow-up intervals prevent any conclusions with regard to long term safety and efficacy. The use of tacrolimus in the clinical setting requires careful consideration of risks versus benefits as well as close monitoring for adverse events. More data from well designed and controlled studies are needed to determine the long-term efficacy and safety of tacrolimus.
Collapse
Affiliation(s)
- Daniel C Baumgart
- Department of Medicine, Division of Gastroenterology & Hepatology , Charité Medical Center, Virchow Hospital , Medical School of the Humboldt-University, Augustenburger Platz 1, Berlin, Germany, 13353.
| | | | | |
Collapse
|
43
|
Grossman AB, Baldassano RN. Specific considerations in the treatment of pediatric inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2008; 2:105-24. [PMID: 19072374 DOI: 10.1586/17474124.2.1.105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Inflammatory bowel disease is one of the most prevalent chronic inflammatory disorders and commonly presents during childhood or adolescence. Occurring during a critical period of growth and development, pediatric Crohn's disease and ulcerative colitis require special consideration. Children often experience growth failure, malnutrition, pubertal delay and bone demineralization. Medical treatment must be optimized to promote clinical improvement and reverse growth failure with minimal toxicity. In addition to pharmacologic and surgical interventions, nutritional therapies play a vital role in the management of pediatric inflammatory bowel disease. This review will outline the epidemiology and clinical complications that are unique to pediatric inflammatory bowel disease, current trends, and recent advances in nutritional and pharmacologic treatment, and projected future therapeutic direction.
Collapse
Affiliation(s)
- Andrew B Grossman
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, PA, USA.
| | | |
Collapse
|
44
|
Benson A, Barrett T, Sparberg M, Buchman AL. Efficacy and safety of tacrolimus in refractory ulcerative colitis and Crohn's disease: a single-center experience. Inflamm Bowel Dis 2008; 14:7-12. [PMID: 17879277 DOI: 10.1002/ibd.20263] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The published experience regarding the use of tacrolimus in Crohn's disease (CD) and ulcerative colitis (UC) refractory to more commonly used medical therapy has been fairly limited. Our objective was to describe our experience with its use in a cohort of patients which, to our knowledge, represents the largest North American cohort described to date. METHODS This was a retrospective, single-center chart analysis. Patients were identified by compiling all hospital discharges with principle diagnoses of ICD-9 codes for 555.0-555.9 (regional enteritis) and 556.0-556.9 (ulcerative colitis) from January 1, 2000, to October 31, 2005, and then cross-referencing the electronic charts for tacrolimus serum concentrations ordered during this time period. Additional patients were identified through verbal communication with participating clinicians. Information abstracted included proportion with clinical response and remission (using a modified disease activity index), ability to wean from steroids, need for surgery / time to surgery, and side-effect profile. RESULTS In all, 32 UC patients and 15 CD patients were identified. The mean disease duration was: UC 81 months (range, 1 month to 37 years), CD 100 months (range, 1 month to 35 years). The disease distribution for UC was: pancolitis 12 (37.5%), extensive colitis 6 (18.8%), left-sided 11 (34.4%), and proctitis 3(9.4%). For CD this was: TI 2 (13.3%), small bowel 2 (13.3%), colonic 3 (20.7%), ileocolonic 7(46.7%), and perianal 1 (6.7%). The duration of tacrolimus treatment for UC was mean, 29 weeks. For CD it was mean, 9.9 weeks. In all, 30/32 UC and 7/15 CD patients were on steroids; 4/30 UC and 0/7 CD patients were able to subsequently wean off steroids. In all, 12/32 UC patients proceeded to colectomy. Mean time to colectomy was 28 weeks and 6/15 CD patients proceeded to a resective surgery. The mean time to surgery was 22 weeks. In all, 22/32 UC patients achieved a clinical response; 3/32 achieved remission and 8/15 CD patients achieved a clinical response; 1/15 achieved remission. Adverse reactions were generally mild. In 6 patients the drug had to be discontinued because of an adverse reaction. There were no opportunistic infections identified, no cases of renal insufficiency related to drug administration, and no deaths while on the medicine. CONCLUSIONS Our experience with tacrolimus in UC and CD indicates that it is safe and relatively well tolerated, although its clinical efficacy is quite variable. More prospective studies assessing its use are necessary.
Collapse
Affiliation(s)
- Aaron Benson
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | | | | | | |
Collapse
|
45
|
Markowitz J. Current treatment of inflammatory bowel disease in children. Dig Liver Dis 2008; 40:16-21. [PMID: 17988965 DOI: 10.1016/j.dld.2007.07.167] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Accepted: 07/26/2007] [Indexed: 12/11/2022]
Abstract
Children with inflammatory bowel disease present formidable therapeutic challenges. As both Crohn's disease and ulcerative colitis remain medically incurable conditions associated with potentially significant morbidity, the focus of treatment must be to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications and minimize the potential psychological effects of these chronic illnesses. This review focuses on the evidence supporting the treatments currently used in children with inflammatory bowel disease, and suggests potential treatment algorithms for particular clinical circumstances.
Collapse
Affiliation(s)
- J Markowitz
- NYU School of Medicine, Division of Pediatric Gastroenterology, Schneider Children's Hospital, North Shore-Long Island Jewish Health System, New Hyde Park, NY, USA.
| |
Collapse
|
46
|
Bremner AR, Beattie RM. Recent advances in the medical therapy of Crohn's disease in childhood. Expert Opin Pharmacother 2007; 8:2553-68. [DOI: 10.1517/14656566.8.15.2553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
47
|
Ziring DA, Wu SS, Mow WS, Martín MG, Mehra M, Ament ME. Oral tacrolimus for steroid-dependent and steroid-resistant ulcerative colitis in children. J Pediatr Gastroenterol Nutr 2007; 45:306-11. [PMID: 17873742 DOI: 10.1097/mpg.0b013e31805b82e4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate tacrolimus in 3 situations: for the induction of remission in children with severe steroid-resistant ulcerative colitis (UC); for steroid sparing in children with steroid-dependent UC in whom treatment with other immunosuppressants fails; and for the maintenance of remission in children with steroid-dependent and steroid-resistant UC. PATIENTS AND METHODS We retrospectively evaluated 18 consecutive patients (13 with pancolitis) who were treated with oral tacrolimus at our institution from May 1999 to October 2005. Nine patients had steroid-resistant UC and 9 patients were steroid-dependent. We started patients initially on tacrolimus 0.2 mg/kg divided twice daily, with a goal plasma trough level of 10 to 15 ng/mL for the first 2 weeks, and then titrated doses to achieve plasma levels between 7 and 12 ng/mL after induction. RESULTS Of the 18 patients in this study, 17 showed a positive response to tacrolimus therapy (ie, cessation of diarrhea and other symptoms) and 5 showed a prolonged response to tacrolimus. The mean time from initiation of tacrolimus therapy until response was 8.5 days. The mean duration of response was 260 days. Eleven of 18 patients required colectomy, including all of the patients with steroid-resistant UC, but only 2 of 9 who were steroid-dependent. The mean time from initiation of tacrolimus until colectomy was 392 days. CONCLUSIONS It is possible that tacrolimus may benefit selected patients with steroid-dependent UC, including those who are intolerant of 6-mercaptopurine or azathioprine. Conversely, patients with steroid-resistant UC are unlikely to sustain a prolonged clinical response to tacrolimus and seem to require colectomy eventually. Careful considerations of risk versus benefit, as well as close monitoring for adverse effects, are essential in all patients.
Collapse
Affiliation(s)
- David A Ziring
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mattel Children's Hospital, David Geffen School of Medicine at the University of California Los Angeles, CA 90095-1752, USA
| | | | | | | | | | | |
Collapse
|
48
|
Abstract
Crohn's disease in childhood is changing. The incidence is increasing, colonic disease is becoming more prevalent in younger children, and colon reconstruction is more acceptable. Genetic phenotypes are influencing decisions for surgery, and targeted immunotherapy has renewed hope for more durable remissions following less extensive resections. The tasks facing the surgeon evaluating a child with Crohn's colitis include confirming the specific diagnostic subtype and selecting the correct procedure. This chapter will review the unique aspects of pediatric Crohn's colitis and the increased complexity of surgical choice for this most challenging presentation. Recent success with less extensive surgery offers renewed hope for children with intractable colonic disease.
Collapse
Affiliation(s)
- Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
| |
Collapse
|
49
|
Abstract
Inflammatory bowel disease (IBD) is a general term used to describe two chronic bowel disorders, Crohn's disease (CD) and ulcerative colitis (UC), both of which are characterized by autoimmune-related inflammation of the intestines. UC is limited to the colonic mucosa, whereas CD can involve any part of the intestinal tract from the mouth to the anus. The true etiology of UC and CD is still unknown, although extensive research has identified some genetic and environmental factors. This article discusses current clinical concepts of both diseases in the pediatric population.
Collapse
Affiliation(s)
- Todd Ponsky
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010-2970, USA
| | | | | |
Collapse
|
50
|
Abstract
Ulcerative colitis (UC) and Crohn disease (CD) are chronic intestinal inflammatory diseases that can present as bloody diarrhea, abdominal pain, and malnutrition. Collectively, these disorders are referred to as inflammatory bowel disease (IBD). All patients with IBD share a common pathophysiology. However, there are a number of developmental, psychosocial, and physiologic issues that are unique to the approximate, equals 20% of patients that present during childhood or adolescence. These include the possibility of disease-induced delays in linear growth or physical development, differences in drug dosing, and the changes in social and cognitive development that occur as children move from school-age years into adolescence and early adulthood. Gastroenterologists caring for these children must therefore develop an optimal regimen of pharmacologic therapies, nutritional management, psychologic support, and properly timed surgery (when necessary) that will maintain disease remission, minimize disease and drug-induced adverse effects, and optimize growth and development. This article reviews current approaches to the management of patients with UC and CD and highlights issues specific to the treatment of children with IBD. The principal medical therapies used to induce disease remission in patients with UC are aminosalicylates (for mild disease), corticosteroids (for moderate disease), and cyclosporine (ciclosporin) (for severe disease). If a patient responds to the induction regimen, maintenance therapies that are used to prevent disease relapse include aminosalicylates, mercaptopurine, and azathioprine. Colectomy with creation of an ileal pouch anal anastomosis (J pouch) has become the standard of care for patients with severe or refractory colitis and results in an improved quality of life in most patients. Therefore, the risks associated with using increasingly potent immunosuppressant agents must be balanced in each case against a patient's desire to retain their colon and avoid a temporary or potentially permanent ileostomy. Decisions about drug therapy in the management of patients with CD are more complex and depend on both the location (e.g. gastroduodenal vs small intestinal vs colonic), as well as the behavior of the disease (inflammatory/mucosal vs stricturing vs perforating) in a given patient. Induction therapies for CD typically include aminosalicylates and antibiotics (for mild mucosal disease), nutritional therapy (including elemental or polymeric formulas), corticosteroids (for moderate disease), and infliximab (for corticosteroid-resistant or fistulizing disease). Aminosalicylates, mercaptopurine, azathioprine, methotrexate, and infliximab can be used as maintenance therapies. Because surgical treatment of CD is not curative, it is typically reserved for those patients either with persistent symptoms and disease limited to a small section of the intestine (e.g. the terminal ileum and cecum) or for the management of complications of the disease including stricture or abdominal abscess. When surgery is necessary, maintenance medications administered postoperatively will postpone recurrence. Patients with UC and CD are at risk for the development of micronutrient deficiencies (including folate, iron, and vitamin D deficiencies) and require close nutritional monitoring. In addition, patients with UC and CD involving the colon are at increased risk of developing colon cancer, and should be enrolled into a colonoscopy surveillance program after 8-10 years of disease duration.
Collapse
Affiliation(s)
- Paul A Rufo
- Center for Inflammatory Bowel Diseases, Combined Program in Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts 02115, USA.
| | | |
Collapse
|