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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: 123] [Impact Index Per Article: 20.5] [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.
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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
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Weckmann M, Schultheiss C, Hollaender A, Bobis I, Rupp J, Kopp MV. Treatment with rhDNase in patients with cystic fibrosis alters in-vitro CHIT-1 activity of isolated leucocytes. Clin Exp Immunol 2016; 185:382-91. [PMID: 27324468 DOI: 10.1111/cei.12827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2016] [Indexed: 11/28/2022] Open
Abstract
Recent data suggest a possible relationship between cystic fibrosis (CF) pharmacotherapy, Aspergillus fumigatus colonization (AC) and/or allergic bronchopulmonary aspergillosis (ABPA). The aim of this study was to determine if anti-fungal defence mechanisms are influenced by CF pharmacotherapy, i.e. if (1) neutrophils form CF and non-CF donors differ in their ability to produce chitotriosidase (CHIT-1); (2) if incubation of isolated neutrophils with azithromycin, salbutamol, prednisolone or rhDNase might influence the CHIT-1 activity; and (3) if NETosis and neutrophil killing efficiency is influenced by rhDNase. Neutrophils were isolated from the blood of CF patients (n = 19; mean age 26·8 years or healthy, non-CF donors (n = 20; 38·7 years) and stimulated with phorbol-12-myristate-13-acetate (PMA), azithromycin, salbutamol, prednisolone or rhDNase. CHIT-1 enzyme activity was measured with a fluorescent substrate. NETosis was induced by PMA and neutrophil killing efficiency was assessed by a hyphae recovery assay. Neutrophil CHIT-1 activity was comparable in the presence or absence of PMA stimulation in both CF and non-CF donors. PMA stimulation and preincubation with rhDNase increased CHIT-1 activity in culture supernatants from non-CF and CF donors. However, this increase was significant in non-CF donors but not in CF patients (P < 0·05). RhDNase reduced the number of NETs in PMA-stimulated neutrophils and decreased the killing efficiency of leucocytes in our in-vitro model. Azithromycin, salbutamol or prednisolone had no effect on CHIT-1 activity. Stimulation of isolated leucocytes with PMA and treatment with rhDNase interfered with anti-fungal defence mechanisms. However, the impact of our findings for treatment in CF patients needs to be proved in a clinical cohort.
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Affiliation(s)
- M Weckmann
- Department of Pediatric Allergy and Pulmonology, Clinic of Pediatrics UKSH, University of Luebeck, Luebeck.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL)
| | - C Schultheiss
- Department of Pediatric Allergy and Pulmonology, Clinic of Pediatrics UKSH, University of Luebeck, Luebeck.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL)
| | - A Hollaender
- Department of Pediatric Allergy and Pulmonology, Clinic of Pediatrics UKSH, University of Luebeck, Luebeck.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL)
| | - I Bobis
- Clinic of Internal Medicine, UKSH, University of Kiel, Kiel
| | - J Rupp
- Department of Molecular and Clinical Infectious Diseases, University of Luebeck, Luebeck, Germany
| | - M V Kopp
- Department of Pediatric Allergy and Pulmonology, Clinic of Pediatrics UKSH, University of Luebeck, Luebeck.,Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL)
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Physician Perspectives on Unresolved Issues in the Management of Ulcerative Colitis: The UC Horizons Project. Inflamm Bowel Dis 2016; 22:583-98. [PMID: 26529561 DOI: 10.1097/mib.0000000000000617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is still uncertainty about what constitutes the best therapeutic practice in ulcerative colitis (UC). OBJECTIVE The purpose of the "UC Horizons Project" was to raise a series of questions regarding the management of UC to provide responses based on the best scientific evidence available. METHODS The 11 members of the scientific committee prepared draft answers to the 10 questions from available evidence after a literature search. A total of 48 Spanish gastroenterology specialists nationwide participated in the project. The national meeting discussed the 10 issues in working groups and reached consensus regarding the recommendations by anonymous, interactive vote following the Delphi methodology. Final answers were developed, based on evidence and clinical experience of the participants. RESULTS All the recommendations achieved a high level of agreement in the plenary vote, although the quality of the evidence was markedly heterogeneous. The lowest percentage of agreement corresponded to the questions with the weakest level of evidence, highlighting the necessity of conducting further studies in these areas. The recommendations focused on (1) aminosalicylates therapy (regarding dose and appropriateness of coadministration with thiopurines), (2) corticosteroid therapy (regarding dose and route of administration), (3) thiopurine treatment (regarding indications and possibility of withdrawal), (4) anti-tumor necrosis factor therapy (regarding appropriateness of combination with thiopurines, intensification, or discontinuation of treatment), and (5) colorectal cancer (regarding risk and time trends). CONCLUSIONS The UC Horizons Project raised a series of eminently practical questions about the management of UC and provided responses based on the best scientific evidence available.
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Llaó J, Naves JE, Ruiz-Cerulla A, Marín L, Mañosa M, Rodríguez-Alonso L, Cabré E, Garcia-Planella E, Guardiola J, Domènech E. Intravenous corticosteroids in moderately active ulcerative colitis refractory to oral corticosteroids. J Crohns Colitis 2014; 8:1523-8. [PMID: 25066954 DOI: 10.1016/j.crohns.2014.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/24/2014] [Accepted: 06/27/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Oral corticosteroids remain the mainstay of treatment for moderately active ulcerative colitis (UC). In patients who fail to respond to oral corticosteroids, attempting the intravenous route before starting rescue therapies is an alternative, although no evidence supports this strategy. AIM To evaluate clinical outcomes after a course of intravenous corticosteroids for moderate attacks of UC according to the failed oral corticosteroids or not. METHODS All episodes of active UC admitted to three university hospitals between January 2005 and December 2011 were identified and retrospectively reviewed. Only moderately active episodes treated with intravenous corticosteroids were included. Treatment outcome was compared between episodes which failed to outpatient oral corticosteroids for the index flare and those directly treated by intravenous corticosteroids. RESULTS 110 episodes were included, 45% of which failed to outpatient oral corticosteroids (median dose 60mg/day [IQR 50-60], median length of course 10days [IQR 7-17]). Initial response (defined as mild severity or inactive disease at day 7 after starting intravenous corticosteroids, without rescue therapy) was achieved in 75%, with no between-group differences (78% vs. 75%). After a median follow-up of 12months (IQR 4-24), 35% of the initial responders developed steroid-dependency and up to 13% required colectomy. Unsuccessful response to oral corticosteroids was the only factor associated with steroid-dependency in the long term (P=0.001). CONCLUSIONS Intravenous corticosteroids are efficient for inducing remission in moderately active UC unresponsive to oral corticosteroids, but almost half of these patients develop early steroid-dependency. Alternative therapeutic strategies should be assessed in this clinical setting.
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Affiliation(s)
- Jordina Llaó
- Hospital de la Santa Creu i Sant Pau (Barcelona), Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Juan E Naves
- Hospital Universitari Germans Trias i Pujol (Badalona), CiberEHD, Catalonia, Spain
| | - Alexandra Ruiz-Cerulla
- Hospital Universitari de Bellvitge, IDIBELL (L'Hospitalet de Llobregat), Catalonia, Spain
| | - Laura Marín
- Hospital de la Santa Creu i Sant Pau (Barcelona), Universitat Autònoma de Barcelona, Catalonia, Spain; Hospital Universitari Germans Trias i Pujol (Badalona), CiberEHD, Catalonia, Spain
| | - Míriam Mañosa
- Hospital Universitari Germans Trias i Pujol (Badalona), CiberEHD, Catalonia, Spain
| | | | - Eduard Cabré
- Hospital Universitari Germans Trias i Pujol (Badalona), CiberEHD, Catalonia, Spain
| | - Esther Garcia-Planella
- Hospital de la Santa Creu i Sant Pau (Barcelona), Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Jordi Guardiola
- Hospital Universitari de Bellvitge, IDIBELL (L'Hospitalet de Llobregat), Catalonia, Spain
| | - Eugeni Domènech
- Hospital Universitari Germans Trias i Pujol (Badalona), CiberEHD, Catalonia, Spain.
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Jeon HH, Lee HJ, Jang HW, Yoon JY, Jung YS, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Clinical outcomes and predictive factors in oral corticosteroid-refractory active ulcerative colitis. World J Gastroenterol 2013; 19:265-273. [PMID: 23345950 PMCID: PMC3547555 DOI: 10.3748/wjg.v19.i2.265] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 10/27/2012] [Accepted: 11/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical outcomes and prognostic factors after intravenous corticosteroids following oral corticosteroid failure in active ulcerative colitis patients.
METHODS: Consecutive patients with moderate to severe ulcerative colitis who had been treated with a course of intravenous corticosteroids after oral corticosteroid therapy failure between January 1996 and July 2010 were recruited at Severance Hospital, Seoul, South Korea. The disease activity was measured by the Mayo score, which consists of stool frequency, rectal bleeding, mucosal appearance at flexible sigmoidoscopy, and Physician Global Assessment. We retrospectively evaluated clinical outcomes at two weeks, one month, three months, and one year after the initiation of intravenous corticosteroid therapy. Two weeks outcomes were classified as responders or non-responders. One month, three month and one year outcomes were classified into prolonged response, steroid dependency, and refractoriness.
RESULTS: Our study included a total of 67 eligible patients. At two weeks, 56 (83.6%) patients responded to intravenous corticosteroids. At one month, complete remission was documented in 18 (32.1%) patients and partial remission in 26 (46.4%). Eleven patients (19.7%) were refractory to the treatment. At three months and one year, we found 37 (67.3%) and 25 (46.3%) patients in prolonged response, ten (18.2%) and 23 (42.6%) patients in corticosteroid dependency, 8 (14.5%) and 6 (11.1%) patients with no response, respectively. Total 9 patients were underwent elective proctocolectomy within 1 year. The duration of oral corticosteroid therapy (> 14 d vs≤ 14 d, P = 0.049) and lower hemoglobin level (≤ 11.0 mg/dL vs >11.0 mg/dL, P = 0.02) were found to be poor prognostic factors for response at two weeks. For one year outcome, univariate analysis revealed that only a partial Mayo score (≥ 6 vs <6, P = 0.057) was found to be associated with a poor response.
CONCLUSION: The duration of oral corticosteroid therapy and lower hemoglobin level were strongly associated with poor outcome.
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Chiorean MV. Oral versus intravenous steroids to define refractory ulcerative colitis. Inflamm Bowel Dis 2011; 17:2503-4. [PMID: 21287674 DOI: 10.1002/ibd.21632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 12/08/2010] [Accepted: 12/10/2010] [Indexed: 12/09/2022]
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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.
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Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
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Turner D, Kolho KL, Mack DR, Raivio T, Leleiko N, Crandall W, Markowitz J, Silverberg MS, Jänne OA, Stempak J, Hyams J, Griffiths AM. Glucocorticoid bioactivity does not predict response to steroid therapy in severe pediatric ulcerative colitis. Inflamm Bowel Dis 2010; 16:469-73. [PMID: 19714760 DOI: 10.1002/ibd.21070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The pathophysiological basis for corticosteroid (CS) failure in ulcerative colitis (UC) is unknown. A transactivation glucocorticoid bioassay (GBA) was developed to measure the biological activity of CS by quantifying glucocorticoid response elements. This approach eliminates differences in bioavailability, chemistry, affinity, and other potential differences between the various steroids regarding their ability to activate the glucocorticoid receptor. In this multicenter prospective study, we aimed to evaluate whether CS bioavailability plays a role in CS refractoriness in severe pediatric UC. METHODS GBA (using COS-1 transfected cells) was measured in the serum of 50 children (52% males, age 13.4 +/- 3.5 years) admitted for acute severe UC on the third day of CS treatment. Demographic, clinical, and laboratory data were prospectively recorded. RESULTS Of the children enrolled, 16 (32%) failed CS therapy and required infliximab (n = 14) or colectomy (n = 2) within a median of 10 days (interquartile range [IQR] 6.5-14.5). Reflecting internal validity of the assay, GBA was highly correlated with the last CS dose and the time interval to bloodletting (r = -0.41 and r = -0.54, respectively; P < 0.001). There was no statistically significant difference in the GBA levels between responders and nonresponders (249 nM versus 200 nM cortisol equivalent, P = 0.18). In a multivariate regression model adjusted for time elapsed from CS and the administered dose, GBA did not predict response to CS (P = 0.34). CONCLUSIONS The lack of correlation of GBA level and treatment outcome lends support to the hypothesis that the bioavailability, type, and dosing of intravenous CS are not associated with response or failure to the drug.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, Jerusalem, Israel.
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Teshima C, Fedorak RN. Are there differences in type, dosage, and method of administration for the systemic steroids in IBD treatment? Inflamm Bowel Dis 2008; 14 Suppl 2:S216-8. [PMID: 18816775 DOI: 10.1002/ibd.20728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Christopher Teshima
- Center of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), Division of Gastroenterology, University of Alberta, Alberta, Canada
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Esteve M, Gisbert JP. Severe ulcerative colitis: At what point should we define resistance to steroids? World J Gastroenterol 2008; 14:5504-7. [PMID: 18810766 PMCID: PMC2746335 DOI: 10.3748/wjg.14.5504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Corticosteroids are still the first-line treatment for active ulcerative colitis more than 50 years after the publication of trials assessing their beneficial effect, with about a 50% remission rate in cases of severe disease. The mortality related to severe attacks of ulcerative colitis has decreased dramatically, to less than 1%, in experienced centers, due to the appropriate use of intensive therapeutic measures (intravenous steroids, fluids and electrolytes, artificial nutritional support, antibiotics, etc), along with timely decision-making about second-line medical therapy and early identification of patients requiring colectomy. One of the most difficult decisions in the management of severe ulcerative colitis is knowing for how long corticosteroids should be administered before deciding that a patient is a non-responder. Studies assessing the outcome of acute attacks after steroid initiation have demonstrated that, in steroid-sensitive patients, the response generally occurs early on, in the first days of treatment. Different indexes to predict treatment failure, when applied on the third day of treatment, have demonstrated a high positive predictive value for colectomy. In contrast to this resolute approach, which is the most widely accepted, other authors have suggested that in some patients a complete and prolonged response to steroids may take longer. Either way, physicians taking care of these patients need to recognize that severe ulcerative colitis may be life-threatening, and they need to be careful with excessively prolonged medical treatment and delayed surgery.
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Irving PM, Gearry RB, Sparrow MP, Gibson PR. Review article: appropriate use of corticosteroids in Crohn's disease. Aliment Pharmacol Ther 2007; 26:313-29. [PMID: 17635367 DOI: 10.1111/j.1365-2036.2007.03379.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Corticosteroids are a well-established treatment for active Crohn's disease and have been widely used for decades. It has become apparent, however, that a proportion of patients either fails to respond to corticosteroids or is unable to withdraw from them without relapsing. Furthermore, their use is associated with a range of side effects, such that long-term treatment carries unacceptable risk. AIM To review the evidence regarding the appropriate use of corticosteroids in Crohn's disease, along with their side effects, safety and alternatives. METHODS To collect relevant articles, a PubMed search was performed from 1966 to November 2006 using the terms 'steroid', 'corticosteroid', 'glucocorticoid', 'prednisolone', 'prednisone', 'methylprednisolone', 'hydrocortisone', 'dexamethasone' and 'budesonide' in combination with 'Crohn(s) disease'. Relevant articles were reviewed, as were their reference lists to identify further articles. RESULTS When used correctly, corticosteroids are a highly effective, well tolerated, cheap and generally safe treatment for active Crohn' disease. Nevertheless, approximately 50% of recipients will either fail to respond (steroid-resistant) or will be steroid dependent at 1 year. Newer alternatives to corticosteroids are not, however, without risk themselves and, moreover, are not necessarily available universally. CONCLUSIONS Steroids are used widely to treat Crohn's disease, a situation that is unlikely to change in the near future. Accordingly, efforts should be made to ensure that they are used correctly and that their side effects are minimized. Reference is made to recently published guidelines and a simplified 'users guide' is presented.
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Affiliation(s)
- P M Irving
- Department of Gastroenterology, Box Hill Hospital and Monash University, Melbourne, Australia
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Lichtenstein GR, Abreu MT, Cohen R, Tremaine W. American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology 2006; 130:940-87. [PMID: 16530532 DOI: 10.1053/j.gastro.2006.01.048] [Citation(s) in RCA: 354] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Gary R Lichtenstein
- Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine Philadelphia, Pennsylvania, USA
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Linehan JD, Kolios G, Valatas V, Robertson DAF, Westwick J. Effect of corticosteroids on nitric oxide production in inflammatory bowel disease: are leukocytes the site of action? Am J Physiol Gastrointest Liver Physiol 2005; 288:G261-7. [PMID: 15374815 DOI: 10.1152/ajpgi.00336.2004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nitric oxide (NO) production is increased in the human colonic mucosa in intestinal inflammation. We examined the effect of corticosteroids and the role of mononuclear cells in this production. Colonic biopsies from patients with ulcerative colitis and normal controls were cultured with either budesonide or prednisolone in the presence of proinflammatory cytokines. Human mixed mononuclear cells (MMCs) were cocultured with HT-29 cells stimulated with IFN-gamma and LPS in the presence or absence of corticosteroids. Nitrite production was measured in supernatants by a modification of the Griess reaction, and inducible NO synthase (iNOS) mRNA expression was studied in colonic tissue by RT-PCR. Both steroids significantly suppressed the nitrite production and iNOS mRNA expression in inflamed colonic biopsies from ulcerative colitis patients and in cytokine-stimulated normal colonic biopsies but not in cytokine-stimulated HT-29 cells. Nitrite production by HT-29 cells was significantly increased (P < 0.01) in cocultures with MMCs stimulated with IFN-gamma and LPS. The presence of either prednisolone or budesonide significantly (P < 0.01) suppressed nitrite production from cocultures of HT-29 cells and MMCs but not from cultures of HT-29 cells stimulated with conditioned media from activated MMCs. Interestingly, stimulation of HT-29 with conditioned media from MMCs pretreated with steroids before stimulation with LPS and IFN-gamma induced a significantly (P < 0.01) lower nitrite production. These results suggest that the inhibitory effect of corticosteroids on the NO production in the intestinal inflammation might be via the inhibition of MMC-produced mediators responsible for NO production by colonic epithelial cells.
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Affiliation(s)
- John D Linehan
- Department of Pharmacology, University of Bath, Bath, United Kingdom
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Affiliation(s)
- R N Fedorak
- Division of Gastroenterology, University of Alberta, Edmonton, Alta., Canada T6G 2C8.
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Abstract
Early identification of patients with acute severe colitis is essential so that prompt treatment can be instigated. Corticosteroids have remained the mainstay of treatment since 1955. The introduction of ciclosporin into the pharmacological armamentarium has reduced early colectomy rates but even with modern medical management up to 30% of patients will still undergo colectomy on the same admission. The overall mortality is now less than 1% in specialist centres compared to 30% in the pre-steroid era. The future promises further advances in treatment through medications that are targeted directly at the underlying inflammatory process.
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Affiliation(s)
- Paul Dunckley
- Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
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Ritchie JK, Ritchie SM, McIntyre PB, Marks CG. Management of Severe Acute Colitis in District Hospitals. Med Chir Trans 1984; 77:465-71. [PMID: 6737405 PMCID: PMC1439816 DOI: 10.1177/014107688407700605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Among 10 hospitals of the North East Thames Region, 84 patients were operated on for inflammatory bowel disease in the years 1977–81. There was one death in the 51 patients treated electively. The postoperative mortality was 24% in 33 patients coming to urgent surgery. The factors leading to this continuing high mortality are analysed as a contribution to an improvement in management.
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Rhodes JM. THERAPEUTIC PROGRESS—REVIEWIX. J Clin Pharm Ther 1983. [DOI: 10.1111/j.1365-2710.1983.tb01100.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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