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Miyazaki R, Sakurai T, Shimada M, Iwashita Y, Shibuya N, Akita Y, Miyashita H, Maruyama Y, Saruta M. Bowel frequency (night) and urgent defecation are improved by budesonide foam in patients with ulcerative colitis: a retrospective observational study. BMC Gastroenterol 2022; 22:310. [PMID: 35751039 PMCID: PMC9233394 DOI: 10.1186/s12876-022-02388-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/16/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction Patients with ulcerative colitis (UC) are known to have a significantly poor quality of life due to bowel frequency (night) and urgent defecation. Budesonide foam is a topical medication that was approved in Japan in 2017 for the treatment of UC. However, its efficacy in the treatment of bowel frequency (night) or urgent defecation is unknown. This study aimed to explore the efficacy of budesonide foam for the alleviation of these symptoms. Methods UC patients who received budesonide foam between December 2017 and January 2020 at the Jikei University School of Medicine in Tokyo were enrolled. The simple clinical colitis activity index (SCCAI) was evaluated at the start of budesonide foam treatment and 2 and 6 weeks later in patients who initially scored ≥ 1 for bowel frequency (night) and urgent defecation, respectively. We also studied the effect of budesonide foam on remaining symptoms in patients who had used 5-aminosalicylic acid (5-ASA) topical treatment, those with SCCAI ≥ 3, and those in remission with residual symptoms (SCCAI 1 or 2). Results Of the 233 enrolled patients, 102 were eligible for the study. In 36 patients with bowel frequency (night) treated with budesonide foam were significantly effective, score in SCCAI decreased from 1.17 ± 0.45 at baseline to 0.53 ± 0.61 at week 2 (p < 0.0001) and 0.17 ± 0.38 at week 6 (p < 0.0001). In 45 patients with urgent defecation score in SCCAI decreased significantly from 1.33 ± 0.52 at baseline to 0.44 ± 0.59 at week 2 (p < 0.0001) and 0.22 ± 0.40 at week 6 (p < 0.0001). Of 22 patients who switched from topical 5-ASA administration to budesonide foam, nine at week 2 (41%) and 11 (50%) at week 6 were improved with no symptoms, and there were no cases of worsened symptoms. No severe side effects associated with budesonide foam were observed. Conclusion Budesonide foam administration significantly improves both bowel frequency (night) and urgent defecation-related UC activity and is also effective for the patients who were refractory to topical 5-ASA administration.
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Affiliation(s)
- Ryosuke Miyazaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toshiyuki Sakurai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mariko Shimada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuko Iwashita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Naoki Shibuya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshihiro Akita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Haruna Miyashita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuki Maruyama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Kruis W, Siegmund B, Lesniakowski K, Simanenkov V, Khimion L, Sobon M, Delmans G, Maksyashina SV, Sablin OA, Pokrotnieks J, Mostovoy Y, Datsenko O, Abdulkhakov S, Dorofeyev A, Levchenko O, Alexeeva O, Andreev P, Kolesnik IP, Mihaly E, Abrahamovych O, Baluta M, Kharchenko N, Viacheslav N, Uspenskiy Y, Vieth M, Mohrbacher R, Mueller R, Greinwald R. Novel Budesonide Suppository and Standard Budesonide Rectal Foam Induce High Rates of Clinical Remission and Mucosal Healing in Active Ulcerative Proctitis: a Randomised, Controlled, Non-inferiority Trial. J Crohns Colitis 2022; 16:1714-1724. [PMID: 35709376 PMCID: PMC9683080 DOI: 10.1093/ecco-jcc/jjac081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Proctitis is the least extensive type of ulcerative colitis, for which rectal therapy is rarely studied and is underused. This study evaluated the efficacy, safety, and patient's preference of a novel formulation of budesonide suppository 4 mg, compared with a commercially available budesonide rectal foam 2 mg, for the treatment of mild to moderate ulcerative proctitis. METHODS This was a randomised, double-blind, double-dummy, active-controlled trial. Patients were randomly assigned in a 1:1 ratio to receive either budesonide 4 mg suppository or budesonide 2 mg foam once daily for 8 weeks. The co-primary endpoints were changes from baseline to Week 8 in clinical symptoms, for which clinical remission was defined as having a modified Ulcerative Colitis-Disease Activity Index [UC-DAI] subscore for stool frequency of 0 or 1 and a subscore for rectal bleeding of 0, and mucosal healing, defined as having a modified UC-DAI subscore for mucosal appearance of 0 or 1. Using a more stringent criterion, we additionally analysed deepened mucosal healing, which was defined as a mucosal appearance subscore of 0. Patient's preference, physician's global assessment, and quality of life were also assessed and analysed. RESULTS Overall, 286 and 291 patients were included in the 4 mg suppository and 2 mg foam groups, respectively. Budesonide 4 mg suppository met the prespecified criterion for non-inferiority to the 2 mg foam in both co-primary endpoints of clinical remission and mucosal healing. Secondary endpoints consistently supported the non-inferiority of the suppository. Trends in favour of the suppository were observed in the subgroup of mesalazine non-responders. More patients reported a preference for the suppository over rectal foam. CONCLUSIONS In patients with ulcerative proctitis, budesonide 4 mg suppository was non-inferior to budesonide 2 mg foam in efficacy, and both were safe and well tolerated.
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Affiliation(s)
- Wolfgang Kruis
- Corresponding author: Wolfgang Kruis, MD, Am Dorfplatz 1, 50259 Freimersdorf, Germany. E-mail:
| | - Britta Siegmund
- Department for Gastroenterology, Infectious diseases and Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Konrad Lesniakowski
- Department VII of Gastroenterology, Hepatologie and Clinical Nutrition, Wojewódzki Szpital Specjalistyczny im. J. Gromkowskiego, Wroclaw, Poland
| | - Vladimir Simanenkov
- State Budgetary Healthcare Institution ‘City Hospital #26’, Saint-Petersburg, Russian Federation
| | - Ludmila Khimion
- Municipal Institution of Kyiv Regional Rada ‘Kyiv Regional Clinical Hospital’, Kyiv, Ukraine
| | - Marcin Sobon
- Centrum Medyczne Pratia Bydgoszcz, Bydgoszcz, Poland
| | - Glebs Delmans
- Endoscopy Department, Daugavpils Regional Hospital, Daugavpils, Latvia
| | - Svetlana V Maksyashina
- State Public Health Institution ‘Novgorod regional clinical hospital’, Velikiy Novgorod, Russian Federation
| | - Oleg A Sablin
- Federal State Budget Public Health Institution All-Russian centre of Emergency and Radiation medicine n. a., A.M.Nikiforov of Ministry of Emergency Situations of Russia, Saint-Petersburg, Russian Federation
| | - Juris Pokrotnieks
- Pauls Stradins Clinical University Hospital, Gastroenterology, Hepatology and Nutrition Centre, Riga, Latvia
| | - Yuriy Mostovoy
- Private small-scale enterprise “Pulse”, Therapeutical Department, Vinnitsya, Ukraine
| | - Olena Datsenko
- Municipal Institution of Healthcare ‘Prof. Shalimova Kharkiv City Clinical Hospital # 2’, Kharkiv, Ukraine
| | - Sayar Abdulkhakov
- Federal State Budget Educational Institution of High Education ‘Kazan State Medical University’, Kazan, Russian Federation,Federal State Autonomous Educational Institution of High Education ‘Kazan [Volga region] Federal University’, Kazan, Russian Federation
| | - Andriy Dorofeyev
- Ukrainian-German Gastroenterology Center ‘BYK-Kyiv’, Kyiv, Ukraine
| | - Olena Levchenko
- Municipal Institution ‘Odesa Regional Clinical Hospital’, Polyclinic department, Odesa, Ukraine
| | - Olga Alexeeva
- State Public Health Institution ‘Nizhny Novgorod regional clinical hospital n.a. N.A.Semashko’, Nizhny Novgorod, Russian Federation
| | - Pavel Andreev
- Non-state Public Health Institution ‘Railway clinical hospital on station Samara’ of JSC ‘Russian railways’, Samara, Russian Federation
| | - Ivan P Kolesnik
- Municipal Institution ‘Zaporizhzhya City Clinical Hospital of Urgent Care’, Surgery department #3, Zaporizhya, Ukraine
| | - Emese Mihaly
- Semmelweis Egyetem ÁOK, II. Belgyógyászati Klinika, Budapest, Hungary
| | - Orest Abrahamovych
- Lviv Regional Clinical Hospital, Gastroenterology department; Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | | | - Nataliia Kharchenko
- Kyiv City Clinical Hospital #8, Department of Gastroenterology. P.L. Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - Neshta Viacheslav
- Municipal Institution ‘City Hospital #1’, Surgery department, Zaporizhya, Ukraine
| | - Yury Uspenskiy
- Saint-Petersburg State Public Health Institution ‘City Hospital of Saint Venerable Martyr Elizabeth’, Saint-Petersburg, Russian Federation
| | - Michael Vieth
- Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Institute of Pathology, Bayreuth, Germany
| | - Ralf Mohrbacher
- Dr. Falk Pharma GmbH, Clinical Research and Development, Freiburg, Germany
| | - Ralph Mueller
- Dr. Falk Pharma GmbH, Clinical Research and Development, Freiburg, Germany
| | - Roland Greinwald
- Dr. Falk Pharma GmbH, Clinical Research and Development, Freiburg, Germany
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Abstract
Anorectal strictures are a notoriously difficult to treat phenotype of perianal Crohn's disease. Quality of life is diminished due to ongoing pain, incontinence, difficulty with stool evacuation, and recurrent medical and surgical treatments. Medical therapy is aimed at treating luminal disease and mucosal ulceration to prevent worsening of fibrosis. Clinical examination and endoscopic intervention can be used for serial dilations of strictures. Unfortunately, despite optimal medical therapy and endoscopic intervention with serial anal dilations, surgery with intestinal diversion or proctocolectomy may be required as part of the treatment algorithm in a significant proportion of patients.
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Affiliation(s)
- Amy L. Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio,Address for correspondence Amy L. Lightner, MD Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic9500 Euclid Ave, Cleveland, OH 44195
| | - Miguel Regueiro
- Department of Gastroenterology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio
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Maconi G, Camatta D, Cannatelli R, Ferretti F, Carvalhas Gabrielli A, Ardizzone S. Budesonide MMX in the Treatment of Ulcerative Colitis: Current Perspectives on Efficacy and Safety. Ther Clin Risk Manag 2021; 17:285-292. [PMID: 33854320 PMCID: PMC8039041 DOI: 10.2147/tcrm.s263835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/17/2021] [Indexed: 12/26/2022] Open
Abstract
Budesonide MMX is a low bioavailability corticosteroid oral once-daily formulation, which has a controlled rate of release throughout the colon, thanks to the multimatrix (MMX) formulation. It has been available for a decade in the USA and Europe for the induction of remission in patients with active, mild to moderate ulcerative colitis, particularly for those not responsive to mesalamine. The efficacy of budesonide MMX in this setting has been assessed by registrative randomized controlled trials showing a higher rate of clinical and endoscopic remission at 8 weeks compared with placebo, mostly in patients with proctosigmoiditis and left-side colitis. Since it is available in our therapeutic armamentarium, a few studies have confirmed the effectiveness of budesonide MMX also in real-life, highlighting the high rate of clinical response and remission and the high safety profile. In the present review, we summarise clinical trials and real-life results of budesonide MMX, assessing its use and predictors of response and non-response in real-life.
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Affiliation(s)
- Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy
| | - Deborah Camatta
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy
| | - Rosanna Cannatelli
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy
| | - Francesca Ferretti
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy
| | - Anna Carvalhas Gabrielli
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy
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Abstract
BACKGROUND Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. OBJECTIVE To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. DATA SOURCES An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. STUDY SELECTION Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. INTERVENTION(S) Medical and surgical management. MAIN OUTCOME MEASURES Symptomatic relief, need for proctocolectomy. RESULTS Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. LIMITATIONS Limited literature published, all retrospective in nature. CONCLUSIONS Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.
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Pastorelli L, Bezzio C, Saibeni S. Hold the Foam: Why Topical Budesonide Remains Relevant for IBD Therapy. Dig Dis Sci 2020; 65:3066-3068. [PMID: 32189103 DOI: 10.1007/s10620-020-06199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Luca Pastorelli
- Gastroenterology Unit, IRCCS Policlinico San Donato, San Donato Milanese, MI, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, MI, Italy
| | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Corso Europa 250, 20017, Rho, MI, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Corso Europa 250, 20017, Rho, MI, Italy.
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7
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Lázaro CM, de Oliveira CC, Gambero A, Rocha T, Cereda CMS, de Araújo DR, Tofoli GR. Evaluation of Budesonide-Hydroxypropyl-β-Cyclodextrin Inclusion Complex in Thermoreversible Gels for Ulcerative Colitis. Dig Dis Sci 2020; 65:3297-3304. [PMID: 31974913 DOI: 10.1007/s10620-020-06075-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/12/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND New formulations for topical treatment of ulcerative colitis with budesonide inclusion complex (BUDHP-β-CD) and poloxamers (PL) were developed for future clinical use. AIMS This study evaluated the efficacy of such novel formulations in a rat model of colitis. METHODS The PL-BUDHP-β-CD systems were prepared by direct dispersion of the complex (BUD concentration 0.5 mg mL-1) in solutions with PL407 or PL403. Male Wistar rats underwent TNBS-induced colitis and were treated for 5 days by a rectal route, as follows: BUD 1: BUDHP-β-CD + PL407 (18%); BUD 2: BUDHP-β-CD + PL407 (20%); BUD 3: BUDHP-β-CD + PL407 (18%) + PL403 (2%); BUD 4: plain BUD; BUD 5: BUDHP-β-CD; C1: HP-β-CD + PL407 (18%); C2: HP-β-CD + PL407 (20%); C3: HP-β-CD + PL407 (18%) + PL403 (2%); C4: saline. A negative control group without colitis was also used. Colitis was assessed via myeloperoxidase (MPO) activity, and macroscopic and microscopic damage score in colon tissues. Protein levels of TNF-α, IL-1β, IL-10 and endogenous glucocorticoids were obtained using ELISA. RESULTS BUDHP-β-CD poloxamer formulations had similar MPO activity when compared with the negative control group. All formulations presented lower MPO activity than BUDHP-β-CD and plain BUD (p < 0.001). BUD 2 produced lower microscopic score values than plain BUD and BUDHP-β-CD (p < 0.01). All formulations with BUDHP-β-CD poloxamers reduced TNF-α levels (p < 0.05). CONCLUSION Novel budesonide inclusion complex formulations improved microscopic damage and reduced colonic MPO activity and TNF-α levels.
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Affiliation(s)
- Carolina Martins Lázaro
- Universidade São Francisco, Av. São Francisco de Assis 218, Bragança Paulista, São Paulo, 12916-900, Brazil
| | - Carolina C de Oliveira
- Universidade São Francisco, Av. São Francisco de Assis 218, Bragança Paulista, São Paulo, 12916-900, Brazil
| | - Alessandra Gambero
- Universidade Estadual de Campinas, Av. Alexandre Cazelatto 999, Paulínia, 13140-000, São Paulo, Brazil
| | - Thalita Rocha
- Universidade São Francisco, Av. São Francisco de Assis 218, Bragança Paulista, São Paulo, 12916-900, Brazil
| | - Cintia Maria Saia Cereda
- Faculdade São Leopoldo Mandic, Instituto de Pesquisa São Leopoldo Mandic, Rua José Rocha Junqueira 13, Campinas, São Paulo, 13045-75, Brazil
| | - Daniele Ribeiro de Araújo
- Universidade Federal do ABC, Av. dos Estados 5001, Bl A, Torre 3, Lab 503-3, Santo André, São Paulo, 09210-170, Brazil
| | - Giovana Radomille Tofoli
- Faculdade São Leopoldo Mandic, Instituto de Pesquisa São Leopoldo Mandic, Rua José Rocha Junqueira 13, Campinas, São Paulo, 13045-75, Brazil.
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Battat R, Duijvestein M, Guizzetti L, Choudhary D, Boland BS, Dulai PS, Parker CE, Nguyen TM, Singh S, Vande Casteele N, Pai RK, Feagan BG, Sandborn WJ, Jairath V. Histologic Healing Rates of Medical Therapies for Ulcerative Colitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Gastroenterol 2019; 114:733-45. [PMID: 30694863 DOI: 10.14309/ajg.0000000000000111] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Histologic remission is a potentially valuable means of assessing disease activity and treatment response in ulcerative colitis (UC). However, the efficacy of existing therapies to achieve this outcome is unclear. We performed a systematic review and meta-analysis of histologic outcomes in UC randomized controlled trials and examined the relationship between histologic and endoscopic outcomes. METHODS MEDLINE, EMBASE, CENTRAL, and the Cochrane IBD Register were searched for randomized controlled trials of aminosalicylates, corticosteroids, immunosuppressives, biologics, and small molecules. Histologic and endoscopic remission and response data were independently extracted and pooled using binomial-normal random-effect or fixed-effect models. Pooled efficacy estimates were calculated as risk ratios (RRs) using the Mantel-Haenszel method. Univariable and multivariable random-effect meta-regression models examined factors associated with histologic remission. RESULTS Seventy-four studies (68 induction and 7 maintenance) were identified. Topical aminosalicylate enemas [37.2%, 95% confidence interval (CI), 29.0-46.3] and suppositories (44.9%, 95% CI, 28.9-62.3) had the highest induction of histologic remission rates. Aminosalicylate enemas (RR = 4.14, 95% CI, 2.35-7.31), aminosalicylate suppositories (RR = 3.94, 95% CI, 1.26-12.32), and budesonide multimatrix (RR = 1.47, 95% CI 1.08-1.99) had higher histologic remission rates than placebo. Data were lacking for biologics and immunosuppressives. The pooled histologic remission rate for placebo in induction studies was 10.4% (95% CI, 7.1-15.2). Histologic and endoscopic remission correlated strongly (r = 0.66; 95% CI, 0.50-0.78). In multivariate analysis of placebo-arm data, less severe clinical disease activity and corticosteroid use were associated with higher histologic remission rates. Similarly, mild clinical disease activity was associated with higher histologic remission rates when active-arm data were analyzed. CONCLUSIONS Histologic remission rates for current UC treatments ranged from 15.0% to 44.9% according to drug class and patient population with the highest rates observed for topical aminosalicylates. Placebo remission rates were low with relatively narrow CIs. These data provide benchmarks to inform future trial design. Histologic remission is a potential treatment target in clinical practice.
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Affiliation(s)
- Cynthia W Ko
- Division of Gastroenterology, University of Washington, Seattle, Washington
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Joseph D Feuerstein
- Division of Gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Corinna Falck-Ytter
- Division of Internal Medicine, Louis Stokes Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Yngve Falck-Ytter
- Division of Gastroenterology, Case Western Reserve University, and Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland
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10
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Abstract
Most patients with ulcerative colitis (UC) have mild-to-moderate disease activity, with low risk of colectomy, and are managed by primary care physicians or gastroenterologists. Optimal management of these patients decreases the risk of relapse and proximal disease extension, and may prevent disease progression, complications, and need for immunosuppressive therapy. With several medications (eg, sulfasalazine, diazo-bonded 5-aminosalicylates [ASA], mesalamines, and corticosteroids, including budesonide) and complex dosing formulations, regimens, and routes, to treat a disease with variable anatomic extent, there is considerable practice variability in the management of patients with mild-moderate UC. Hence, the American Gastroenterological Association prioritized clinical guidelines on this topic. To inform clinical guidelines, this technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework for interventional studies. Focused questions included the following: (1) comparative effectiveness and tolerability of different oral 5-ASA therapies (sulfalsalazine vs diazo-bonded 5-ASAs vs mesalamine; low- (<2 g) vs standard (2-3 g/d) vs high-dose (>3 g/d) mesalamine); (2) comparison of different dosing regimens (once-daily vs multiple times per day dosing) and routes (oral vs rectal vs both oral and rectal); (3) role of oral budesonide in patients mild-moderate UC; (4) comparative effectiveness and tolerability of rectal 5-ASA and corticosteroid formulations in patients with distal colitis; and (5) role of alternative therapies like probiotics, curcumin, and fecal microbiota transplantation in the management of mild-moderate UC.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA
| | - Joseph D. Feuerstein
- Division of Gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center, Boston, MA
| | - David G. Binion
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
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11
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Zhang Y, Chen D, Wang F, Li X, Xue X, Jiang M, Xu B, Chu Y, Wang W, Wu K, Mao R, Shen J, Yang S, Liang J. Comparison of the efficiency of different enemas on patients with distal ulcerative colitis. Cell Prolif 2019; 52:e12559. [PMID: 30659678 PMCID: PMC6496853 DOI: 10.1111/cpr.12559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives Rectal application of steroids and 5‐aminosalicylic acid (5‐ASA) is associated with few side effects and has a high therapeutic efficacy in left‐sided colitis. Previous studies have shown that rectal administration of both steroids and 5‐ASA is superior to one single alone. However, some reports are still controversial. Therefore, it is necessary to investigate the treatment choice and efficacy of these different enemas in distal ulcerative colitis (UC) patients. Materials and Methods Questionnaire survey and a retrospective study were carried out in Chinese hospitals to investigate the efficacy of 5‐ASA or hydrocortisone/dexamethasone or their combination enema in patients with distal active UC. Dextran sodium sulphate (DSS)‐induced colitis model in mice was also utilized to evaluate the effects in vivo. Results The results from questionnaire survey showed that majority of physicians would prefer oral 5‐ASA with topical 5‐ASA therapy for distal UC patients. However, 43.01% of physicians would like to choose oral 5‐ASA and topical hydrocortisone/dexamethasone with or without 5‐ASA enema. A retrospective study demonstrated that 5‐ASA enema or 5‐ASA combined with hydrocortisone/dexamethasone enema therapy was superior to hydrocortisone/dexamethasone enema to decrease C‐reactive protein, erythrocyte sedimentation rate (ESR), Mayo score and induce clinical remission and clinical response. No superiority of combination therapy was further proved in DSS‐induced colitis in mice. Conclusions Although 43.01% of physicians would like to choose hydrocortisone/dexamethasone with or without 5‐ASA enema for the treatment of distal UC, the combination was not superior to 5‐ASA enema. Hydrocortisone/dexamethasone enema with 5‐ASA enema is not recommended for distal active UC patients.
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Affiliation(s)
- Yujie Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Di Chen
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Fang Wang
- Department of Gastroenterology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xiaowei Li
- Department of Gastroenterology, Navy General Hospital, Beijing, China
| | - Xianmin Xue
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Mingzuo Jiang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Bing Xu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Yi Chu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Weijie Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jun Shen
- Department of Digestive Diseases, Shanghai RenJi Hospital, Shanghai, China
| | - Shaoqi Yang
- Department of Gastroenterology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Jie Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, China
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Kruis W, Neshta V, Pesegova M, Alekseeva O, Andreev P, Datsenko O, Levchenko O, Abdulkhakov S, Lozynskyy Y, Mostovoy Y, Soloviev K, Dorofeyev AE, Vieth M, Stiess M, Greinwald R, Mohrbacher R, Siegmund B. Budesonide Suppositories Are Effective and Safe for Treating Acute Ulcerative Proctitis. Clin Gastroenterol Hepatol 2019; 17:98-106.e4. [PMID: 29702300 DOI: 10.1016/j.cgh.2018.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 04/05/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although proctitis is the most limited form of ulcerative colitis, it causes unpleasant symptoms. Topical mesalamine, the standard treatment, is not always effective. We conducted a randomized phase 2 trial to determine the efficacy and safety of 2 doses of a budesonide suppository vs mesalamine suppositories vs combined budesonide and mesalamine suppositories for proctitis. METHODS We performed a prospective, double-blind, double-dummy, multicenter trial in 337 patients with active proctitis to compare the efficacies of 4 different suppository treatments. Patients were randomly assigned to groups given 2 mg budesonide suppositories (2 mg BUS; n = 89 patients), 4 mg BUS (n = 79), 1 g mesalamine suppositories (1 g MES; n = 81), or the combination of 2 mg BUS and 1 g MES (n = 88). The study was performed from November 2013 through July 2015 at 36 study sites in Europe and Russia. The primary end point was the time to resolution of clinical symptoms, defined as the first of 3 consecutive days with a score of 0 for rectal bleeding and stool frequency. RESULTS The mean time to resolution of symptoms in the 4 mg BUS (29.8 days) and combination of 2 mg BUS and 1 g MES (29.3 days) groups resembled that of the standard 1 g MES treatment (29.2 days), but was significantly longer in the 2 mg BUS group (35.5 days). Furthermore, proportions of patients with deep, clinical, and endoscopic remission, as well as mucosal healing, were similar among the 1 g MES, 4 mg BUS, and combination therapy groups, but significantly lower in the group that received 2 mg BUS. No safety signals were observed, and the patients' treatment acceptance was high (67%-85% of patients). CONCLUSIONS In a multicenter randomized trial, we found that the efficacy and safety of 4 mg BUS in treatment of active proctitis did not differ significantly from those of 1 g MES. Budesonide suppositories offer an alternative therapy to mesalamine for topical treatment of proctitis. Clinicaltrialsregister.eu no: 2012-003362-41.
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Pineton de Chambrun G, Tassy B, Kollen L, Dufour G, Valats JC, Bismuth M, Funakoshi N, Panaro F, Blanc P. The treatment of refractory ulcerative colitis. Best Pract Res Clin Gastroenterol 2018; 32-33:49-57. [PMID: 30060939 DOI: 10.1016/j.bpg.2018.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/25/2018] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
Abstract
Ulcerative proctitis is defined as a mucosal inflammation limited to the rectum. Ulcerative proctitis is responsible for distressing symptoms and alteration of patient quality of life. Effective treatment is important to prevent or delay proximal extension of the disease and to improve quality of life. Refractory ulcerative proctitis is defined as the failure of topical and oral 5-aminosalicylic acid and corticosteroids. Medical management of refractory ulcerative proctitis may be challenging as there is little evidence regarding drug efficacy in this clinical situation. Data are currently available for azathioprine, topical tacrolimus and anti-TNF monoclonal antibodies as rescue treatment for refractory ulcerative proctitis. Other biologics may be of benefit despite a lack of dedicated clinical trials. Ultimately, experimental therapies such as epidermal growth factor enemas, appendectomy or fecal transplantation may be tried before restorative proctocolectomy with J pouch anastomosis, which has demonstrated good results with regards to clinical remission and quality of life.
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Mohammed Vashist N, Samaan M, Mosli MH, Parker CE, MacDonald JK, Nelson SA, Zou GY, Feagan BG, Khanna R, Jairath V. Endoscopic scoring indices for evaluation of disease activity in ulcerative colitis. Cochrane Database Syst Rev 2018; 1:CD011450. [PMID: 29338066 PMCID: PMC6491285 DOI: 10.1002/14651858.cd011450.pub2] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Endoscopic assessment of mucosal disease activity is routinely used to determine eligibility and response to therapy in clinical trials of ulcerative colitis. The operating properties of the existing endoscopic scoring indices are unclear. OBJECTIVES A systematic review was undertaken to evaluate the development and operating characteristics of endoscopic scoring indices for the evaluation of ulcerative colitis. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2016. We also searched references and conference proceedings (Digestive Disease Week, United European Gastroenterology Week, European Crohn's and Colitis Organization). SELECTION CRITERIA Any study design (e.g. randomized controlled trials, cohort studies, case series) that evaluated endoscopic indices for evaluation of ulcerative colitis disease activity were considered for inclusion. Eligible participants were adult patients (> 16 years), diagnosed with ulcerative colitis using conventional clinical, radiologic and endoscopic criteria. DATA COLLECTION AND ANALYSIS Two authors independently reviewed the studies identified from the literature search. These authors also independently extracted and recorded data on the number of patients enrolled; number of patients per treatment arm; patient characteristics including age and gender distribution; endoscopic index; and outcomes such as reliability (intra-rater and inter-rater), validity (content, construct, criterion), responsiveness and feasibility. Any disagreements regarding study inclusion or data extraction were resolved by discussion and consensus with a third author. Risk of bias was assessed by determining whether assessors were blinded to clinical information and whether assessors scored the endoscopic index independently. We also assessed the methodological quality of the validation studies using the COSMIN checklist MAIN RESULTS: A total of 23 reports of 20 studies met the pre-defined inclusion criteria and were included in the review. Of the 20 included validation studies, 19 endoscopic scoring indices were assessed, including the Azzolini Classification, Baron Score, Blackstone Endoscopic Interpretation, Chinese Grading System of Ulcerative Colitis, Endoscopic Activty Index, Jeroen Score, Magnifying Colonoscopy Grade, Matts Score, Mayo Clinic Endoscopic Subscore, Modified Baron Score, Modified Mayo Clinic Endoscopic Subscore, Osada Score, Rachmilewtiz Endoscopic Score, St. Mark's Index, Ulcerative Colitis Colonoscopic Index of Serverity (UCCIS), endoscopic component of the Ulcerative Colitis Disease Activity Index (UCDAI), Ulcerative Colitis Endoscopic Index of Severity (UCEIS), Witts Sigmoidoscopic Score and Watson Grade. The individuals who performed the endoscopic scoring were blinded to clinical and/or histologic information in ten of the included studies, not blinded to clinical and/or histologic information in one of the included studies, and it was unclear whether blinding occurred in the remaining nine included studies. Independent observation was confirmed in four of the included studies, unclear in five of the included studies, and non-applicable (since inter-rater reliability was not assessed) in the remaining eleven included studies. The methodological quality (COSMIN checklist) of most of the included studies was rated as 'good' or 'excellent'. One study that assessed responsiveness was rated as 'fair'. The inter-rater reliability of nine endoscopic scoring indices including the Baron Score, Blackstone Endoscopic Interpretation, Endoscopic Activity Index, Matts Score, Mayo Clinic Endoscopic Subscore, Osada Score, UCCIS, UCEIS, Watson Grade was assessed in seven studies, with estimates of correlation, ƙ, ranging from 0.44 to 0.97. The iIntra-rater reliability of seven endoscopic scoring indices including the Baron Score, Blackstone Endoscopic Interpretation, Matts Score, Mayo Clinic Endoscopic Subscore, Osada Score, UCCIS and UCEIS was assessed in three studies, with estimates of correlation, ƙ, ranging from 0.41 to 0.86. No studies assessed content validity. Three studies evaluated the criterion validity of three endoscopic scoring indices including the Rachmilewitz Endoscopic Score, Magnifying Colonoscopy Grade and the UCCIS. These indices were correlated with objective markers of disease activity including albumin, blood leukocytes, C-reactive protein, fecal calprotectin, hemoglobin, mucosal interleukin-8 concentration and platelet count. Correlation estimates ranged from r = -0.19 to 0.83. Thirteen endoscopic scoring indices were tested for construct validity in 13 studies. Estimates of correlation between the endoscopic scoring indices and other measures of disease activity ranged from r = 0.27 to 0.93. Two studies explored the responsiveness of four endoscopic scoring indices including the Mayo Endoscopic Subscore, Modified Baron Score, Modified Mayo Endoscopic Subscore and UCEIS. One study concluded that the Modified Baron Score, Modified Mayo Endoscopic Subscore and UCEIS had similar responsiveness for detecting disease change in ulcerative colitis. The other included study concluded that the UCEIS may be the most accurate endoscopic scoring tool. None of the included studies formally assessed feasibility. AUTHORS' CONCLUSIONS While the UCEIS, UCCIS and Mayo Clinic Endoscopic Subscore have undergone extensive validation, none of these instruments have been fully validated and only two studies assessed responsiveness. Further research on the operating properties of these indices is needed given the lack of a fully-validated endoscopic scoring instrument for the evaluation of disease activity in ulcerative colitis.
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Affiliation(s)
| | - Mark Samaan
- Academic Medical CenterMeibergdreef 9 ‐ C2‐112AmsterdamNetherlands1105 AZ
| | - Mahmoud H Mosli
- King Abdulaziz UniversityKing Abdulaziz University HospitalJeddahSaudi Arabia
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | | | - GY Zou
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Brian G Feagan
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Reena Khanna
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - Vipul Jairath
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
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15
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Naganuma M, Aoyama N, Tada T, Kobayashi K, Hirai F, Watanabe K, Watanabe M, Hibi T. Complete mucosal healing of distal lesions induced by twice-daily budesonide 2-mg foam promoted clinical remission of mild-to-moderate ulcerative colitis with distal active inflammation: double-blind, randomized study. J Gastroenterol 2018; 53:494-506. [PMID: 28779419 PMCID: PMC5866841 DOI: 10.1007/s00535-017-1376-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/24/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Budesonide foam is used for the topical treatment of distal ulcerative colitis. This phase III study was performed to confirm mucosal healing and other therapeutic effects of twice-daily budesonide 2-mg foam in patients with mild-to-moderate ulcerative colitis including left-sided colitis and pancolitis. METHODS This was a multicenter, randomized, placebo-controlled, double-blind trial. A total of 126 patients with mild-to-moderate ulcerative colitis with active inflammation in the distal colon were randomized to two groups receiving twice-daily budesonide 2 mg/25 ml foam or placebo foam. The primary endpoint was the percentage of complete mucosal healing of distal lesions (endoscopic subscore of 0) at week 6. Some patients continued the treatment through week 12. Drug efficacy and safety were evaluated. RESULTS The percentages of both complete mucosal healing of distal lesions and clinical remission were significantly improved in the budesonide as compared with the placebo group (p = 0.0003 and p = 0.0035). Subgroup analysis showed similar efficacy of budesonide foam for complete mucosal healing of distal lesions and clinical remission regardless of disease type. The clinical remission percentage tended to be higher in patients achieving complete mucosal healing of distal lesions than in other patients. There were no safety concerns with budesonide foam. CONCLUSIONS This study confirmed for the first time complete mucosal healing with twice-daily budesonide 2-mg foam in mild-to-moderate ulcerative colitis with distal active inflammation. The results also indicated that complete mucosal healing of distal lesions by budesonide foam promotes clinical remission of ulcerative colitis. Clinical trial registration no.: Japic CTI-142704.
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Affiliation(s)
- Makoto Naganuma
- Department of Gastroenterology and Hepatology, School of Medicine, Keio University, Shinanomachi 35, Shinjuku-ku, Tokyo, 160-0016, Japan.
| | - Nobuo Aoyama
- Gastrointestinal Endoscopy and Inflammatory Bowel Disease Center, Aoyama Medical Clinic, Hyogo, Japan
| | - Tomohiro Tada
- Tada Tomohiro Institute of Gastroenterology and Proctology, Saitama, Japan
| | - Kiyonori Kobayashi
- Department of Research and Development Center for New Medical Frontiers, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Kenji Watanabe
- Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
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Zhao X, Zhou C, Ma J, Zhu Y, Sun M, Wang P, Zhang Y, Ma H, Zhang H. Efficacy and safety of rectal 5-aminosalicylic acid versus corticosteroids in active distal ulcerative colitis: a systematic review and network meta-analysis. Sci Rep 2017; 7:46693. [PMID: 28440311 PMCID: PMC5404224 DOI: 10.1038/srep46693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/24/2017] [Indexed: 12/14/2022] Open
Abstract
Topical 5-aminosalicylic acid (5-ASA) and corticosteroids are used frequently in the treatment of active distal ulcerative colitis (UC). Our study aimed to determine the efficacy and safety of different topical drugs used to treat active distal UC. A random-effects model within a Bayesian framework was utilized to compare treatment effects and safety as odds ratios (ORs) with corresponding 95% credible intervals (CrI). The surface under the cumulative ranking area (SUCRA) and median rank (MR) with corresponding 95% CrI were calculated to rank the treatment outcomes. In the induction of clinical and endoscopic remission, most regimens showed significant advantages over placebo except topical budesonide 0.5 mg/d and hydrocortisone 100 mg/d. According to SUCRA and MR values, rectal 5-ASA 1.5 to 2.0 g/d + Beclomethasone dipropionate (BDP) 3 mg/d rendered the highest probability of being the best regimen to achieve clinical and endoscopic remission, followed by the separate use of 5-ASA 4 g/d and BDP 3 mg/d. The occurrence of adverse events was not significantly different between each treatments and placebo. In conclusion, the combined use of topical 5-ASA and BDP proved to be the best choice for active distal UC and further well-designed researches are warranted to assess its efficacy and safety.
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Affiliation(s)
- Xiaojing Zhao
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Changcheng Zhou
- Department of Urology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, Jiangsu 210006, China
| | - Jingjing Ma
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yunjuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Min Sun
- Department of Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Peixue Wang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yi Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Haiqin Ma
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hongjie Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Choi CH, Moon W, Kim YS, Kim ES, Lee BI, Jung Y, Yoon YS, Lee H, Park DI, Han DS. Second Korean guidelines for the management of ulcerative colitis. Intest Res 2017; 15:7-37. [PMID: 28239313 PMCID: PMC5323310 DOI: 10.5217/ir.2017.15.1.7] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 12/12/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by a relapsing and remitting course. The direct and indirect costs of the treatment of UC are high, and the quality of life of patients is reduced, especially during exacerbation of the disease. The incidence and prevalence of UC in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Various medical and surgical therapies, including biologics, are currently used for the management of UC. However, many challenging issues exist, which sometimes lead to differences in practice between clinicians. Therefore, the IBD study group of the Korean Association for the Study of Intestinal Diseases established the first Korean guidelines for the management of UC in 2012. This is an update of the first guidelines. It was generally made by the adaptation of several foreign guidelines as was the first edition, and encompasses treatment of active colitis, maintenance of remission, and indication of surgery for UC. The specific recommendations are presented with the quality of evidence and classification of recommendations.
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Affiliation(s)
- Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Eun Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
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Choi CH, Moon W, Kim YS, Kim ES, Lee BI, Jung Y, Yoon YS, Lee H, Park DI, Han DS. Second Korean Guideline for the Management of Ulcerative Colitis. Korean J Gastroenterol 2017; 69:1-28. [DOI: 10.4166/kjg.2017.69.1.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Eun Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
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Abstract
INTRODUCTION Budesonide is a synthetic corticosteroid characterized by enhanced topical potency and limited systemic bioavailability. Its use in ulcerative colitis (UC) was limited to rectal preparations until recently when the new oral budesonide formulation incorporating the multi-matrix system technology was introduced. The purpose of this review is to evaluate the current role of oral and rectal budesonide in managing UC patients Areas covered: In this paper, we described the chemical structure and pharmacologic characteristics of the different oral and rectal budesonide preparations, provided a summary of the published trials that evaluated the efficacy and safety of budesonide in UC, and discussed the current status of its use in this population Expert opinion: Budesonide is effective in inducing remission in a subset of patients with mild-moderate UC. Nevertheless, the current evidence suggests inferiority of oral budesonide to 5-aminosalisylates (5-ASA) and systemic steroids, whereas rectal applications are comparable to other rectal steroid preparations, but still inferior to rectal 5-ASA. In clinical practice, several issues need clarification including, its exact position in the line of induction agents; the role of combining budesonide and 5-ASAs; the role of combining oral and rectal budesonide; and the role of budesonide in maintenance therapy.
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Affiliation(s)
- Maisa I Abdalla
- a Department of Medicine, Division of Gastroenterology and Hepatology , University of North Carolina , Chapel Hill , NC , USA
| | - Hans Herfarth
- a Department of Medicine, Division of Gastroenterology and Hepatology , University of North Carolina , Chapel Hill , NC , USA
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Kucharski M, Karczewski J, Mańkowska-Wierzbicka D, Karmelita-Katulska K, Grzymisławski M, Kaczmarek E, Iwanik K, Rzymski P, Swora-Cwynar E, Linke K, Dobrowolska A. Applicability of endoscopic indices in the determination of disease activity in patients with ulcerative colitis. Eur J Gastroenterol Hepatol 2016; 28:722-30. [PMID: 26894632 DOI: 10.1097/MEG.0000000000000601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The combination of clinical remission and mucosal healing represents a major goal of different treatment strategies for ulcerative colitis (UC). This study aimed to assess which of the endoscopic indices used to evaluate mucosal changes in UC are correlated with clinical indices currently used to determine disease activity, as well as which of the endoscopic indices are correlated with the Geboes Index used for histological evaluation. It also aimed to find correlations between the currently used clinical activity indices and the histological Geboes Index. METHODS A group of 49 patients with a confirmed diagnosis of UC and a group of 52 individuals without a diagnosis of gastrointestinal disease, who constituted the control group, were investigated. All patients were evaluated by colonoscopy, and the severity of mucosal changes was scored in terms of nine different endoscopic indices commonly used in both pharmacological trials and clinical practice. Evaluation was also carried out using clinical and histological indices. Endoscopic indices used for UC were then correlated with different clinical and histological indices to find the strongest correlations. RESULTS AND CONCLUSION A high correlation was demonstrated between three of the 11 evaluated clinical indices - Improvement Based on Individual Symptom Scores, Ulcerative Colitis Disease Activity Index, and Schroeder Index - and all nine endoscopic indices - Ulcerative Colitis Endoscopic Index of Severity, Baron Score, Schroeder Index, Feagan Index, Powell-Tuck Index, Rachmilewitz Index, Sutherland Index, Lofberg Index, and Lemman Index. Improvement Based on Individual Symptom Scores was the index with the highest correlation with all the endoscopic indices used for UC. The above indices are recommended for clinical evaluation of UC activity. The Ulcerative Colitis Endoscopic Index of Severity was moderately correlated with a histological index, and it is therefore recommended for routine endoscopic mucosal evaluation in patients with UC.
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Bressler B, Marshall JK, Bernstein CN, Bitton A, Jones J, Leontiadis GI, Panaccione R, Steinhart AH, Tse F, Feagan B. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Gastroenterology 2015; 148:1035-1058.e3. [PMID: 25747596 DOI: 10.1053/j.gastro.2015.03.001] [Citation(s) in RCA: 267] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 02/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The medical management of ulcerative colitis (UC) has improved through the development of new therapies and novel approaches that optimize existing drugs. Previous Canadian consensus guidelines addressed the management of severe UC in the hospitalized patient. We now present consensus guidelines for the treatment of ambulatory patients with mild to severe active UC. METHODS A systematic literature search identified studies on the management of UC. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a working group of specialists. RESULTS The participants concluded that the goal of therapy is complete remission, defined as both symptomatic and endoscopic remission without corticosteroid therapy. The consensus includes 34 statements focused on 5 main drug classes: 5-aminosalicylate (5-ASA), corticosteroids, immunosuppressants, anti-tumor necrosis factor (TNF) therapies, and other therapies. Oral and rectal 5-ASA are recommended first-line therapy for mild to moderate UC, with corticosteroid therapy for those who fail to achieve remission. Patients with moderate to severe UC should undergo a course of oral corticosteroid therapy, with transition to 5-ASA, thiopurine, anti-TNF (with or without thiopurine or methotrexate), or vedolizumab maintenance therapy in those who successfully achieve symptomatic remission. For patients with corticosteroid-resistant/dependent UC, anti-TNF or vedolizumab therapy is recommended. Timely assessments of response and remission are critical to ensuring optimal outcomes. CONCLUSIONS Optimal management of UC requires careful patient assessment, evidence-based use of existing therapies, and thorough assessment to define treatment success.
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Affiliation(s)
- Brian Bressler
- Division of Gastroenterology, Department of Medicine, St Paul's Hospital, Vancouver, British Columbia.
| | - John K Marshall
- Department of Medicine, McMaster University, Hamilton, Ontario
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec
| | - Jennifer Jones
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan
| | | | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta
| | | | - Francis Tse
- Department of Medicine, McMaster University, Hamilton, Ontario
| | - Brian Feagan
- Robarts Research Institute, Western University, London, Ontario, Canada
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Mosli M, Samaan M, Nelson SA, Feagan BG, Travis S, D'Haens G, Sandborn WJ, Zou GY, MacDonald JK, Levesque BG. Endoscopic scoring indices for evaluation of disease activity in ulcerative colitis. Hippokratia 2015. [DOI: 10.1002/14651858.cd011450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mahmoud Mosli
- London Health Sciences Centre, Victoria Hospital; Room E1-317 800 Commissioners Rd E London ON Canada N6A 5W9
- King Abdulaziz University; King Abdulaziz University Hospital; Jeddah Saudi Arabia
| | - Mark Samaan
- Academic Medical Center; Inflammatory Bowel Disease Centre; Meibergdreef 9 - C2-112 Amsterdam Netherlands 1105 AZ
| | | | - Brian G Feagan
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
| | - Simon Travis
- University of Oxford; Nuffield Department of Medicine; Oxford UK
| | - Geert D'Haens
- Academic Medical Center; Meibergdreef 9 - C2-112 Amsterdam Netherlands 1105 AZ
| | - William J Sandborn
- University of California San Diego; Division of Gastroenterology; La Jolla California USA
| | - GY Zou
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
| | - John K MacDonald
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London ON Canada N6A 5K8
| | - Barrett G Levesque
- University of California San Diego; Division of Gastroenterology; La Jolla California USA
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Probert CSJ, Dignass AU, Lindgren S, Oudkerk Pool M, Marteau P. Combined oral and rectal mesalazine for the treatment of mild-to-moderately active ulcerative colitis: rapid symptom resolution and improvements in quality of life. J Crohns Colitis 2014; 8:200-7. [PMID: 24012063 DOI: 10.1016/j.crohns.2013.08.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 08/01/2013] [Accepted: 08/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Mesalazine (5-aminosalicylic acid) is the standard first-line therapy for mild-to-moderate ulcerative colitis. In the PINCE study, remission rates were significantly greater with combined oral/enema vs. oral/placebo treatment at 8 weeks (64% vs. 43%, respectively; p=0.030). In this analysis, we explored early response, mucosal healing rates, cessation of rectal bleeding, and quality of life in PINCE. METHODS Patients with extensive mild-to-moderately active ulcerative colitis received 8weeks of oral mesalazine 4 g/day, plus 4 weeks of daily active (1g mesalazine) or placebo enema. Early response was assessed using the abbreviated ulcerative colitis disease activity index. Mucosal healing was assessed by disease activity index endoscopic mucosal appearance score. Cessation of bleeding (patient diaries), quality of life (EQ-5D), and patient acceptability (questionnaire) were also assessed. RESULTS Combined mesalazine oral/enema treatment achieved a significantly higher rate of improvement in abbreviated ulcerative colitis disease activity index (score decrease ≥ 2) within 2 weeks, compared with oral-only treatment (p = 0.032). Bleeding ceased significantly more quickly with combination vs. oral therapy (p = 0.003). More patients showed mucosal healing (disease activity index endoscopic mucosal appearance score 0/1) with combination vs. oral therapy, which was significantly different between groups at week 4 (p = 0.052). Both groups showed quality of life improvements, with a significant benefit for combination vs. oral therapy at week 4 in multiple domains. Most patients reported finding the treatment acceptable. CONCLUSIONS Rapid cessation of symptoms was seen with combination therapy, which is particularly important to patients and may improve quality of life.
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Affiliation(s)
| | - Axel U Dignass
- Department of Gastroenterology, Hepatology and Oncology, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Stefan Lindgren
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Gastroenterology, University Hospital Skane, Malmö, Sweden
| | | | - Philippe Marteau
- Department of Hepato-gastroenterology, AP-HP, Lariboisière Hospital, Paris, France; Denis Diderot Paris 7 University, Paris, France
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Mosli MH, Feagan BG, Sandborn WJ, Dʼhaens G, Behling C, Kaplan K, Driman DK, Shackelton LM, Baker KA, Macdonald JK, Vandervoort MK, Geboes K, Levesque BG. Histologic evaluation of ulcerative colitis: a systematic review of disease activity indices. Inflamm Bowel Dis 2014; 20:564-75. [PMID: 24412993 DOI: 10.1097/01.MIB.0000437986.00190.71] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) is an idiopathic inflammatory disorder. Currently, the main goals of treatment are to induce and maintain clinical and/or endoscopic remission. However, evidence indicates that persistent disease activity on colonic biopsies in the setting of clinical or endoscopic remission is an independent predictor of poor outcomes. A number of previous studies have proposed histologic indices for use in specific trials of UC. The aim of this study was to systematically review the existing histological indices for UC and assess their potential use in both patient management and clinical trials. METHODS We performed a systematic review of histological indices evaluating disease activity in UC. MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library (CENTRAL), and Digestive Diseases Week (DDW) abstracts of randomized and/or controlled trials clinical trials were searched from inception to February 2013 for applicable studies. Data from these studies were reviewed and analyzed. RESULTS After systematically applying inclusion criteria, we identified 108 scientific articles including 88 clinical studies and 21 related clinical reviews. Eighteen indices of histological activity in UC were identified and reviewed. CONCLUSIONS Although multiple histological scoring indices for assessment of UC disease activity currently exist, none of these instruments were developed using a formal validation process and their operating properties remain poorly understood. Future studies are needed to address this deficiency.
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Gionchetti P, Praticò C, Rizzello F, Calafiore A, Capozzi N, Campieri M, Calabrese C. The role of Budesonide-MMX in active ulcerative colitis. Expert Rev Gastroenterol Hepatol 2014; 8:215-22. [PMID: 24502535 DOI: 10.1586/17474124.2014.887437] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Traditional corticosteroids represent a well-established and effective treatment for active ulcerative colitis (UC). However, the severity of their systemic side effects, led in recent years to look for new steroid molecules that could reduce them, maximizing the anti-inflammatory activity. Budesonide has been one of the most studied steroid compounds and it has been approved for the treatment of mild to moderate active Crohn's disease (CD). In order to extend the release until the distally located inflammation, budesonide has been coupled with a controlled delivery system, called Multi-Matrix system (MMX), already successfully tested with oral mesalazine for the treatment of distal UC. After in vitro and in vivo models, the efficacy of Budesonide-MMX has been investigated in active UC with a first small phase II study, and partially encouraging results. This article will review the evidences on the use of budesonide in inflammatory bowel diseases and will discuss the role of Budesonide-MMX in active UC nowadays.
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Stewart MJ, Kutcher M, Storr M, Seow CH. Interventions for induction of mucosal healing in ulcerative colitis. Hippokratia 2014. [DOI: 10.1002/14651858.cd010997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Michael J Stewart
- Cedars-Sinai Medical Center; Inflammatory Bowel Disease Center; Los Angeles California USA
| | - Matthew Kutcher
- Dalhousie University; Faculty of Medicine; Halifax Nova Scotia Canada
| | - Martin Storr
- University of Munich; Department of Medicine; Marchioninistr 15 Munich Germany 81377
| | - Cynthia H Seow
- University of Calgary; Departments of Medicine & Community Health Sciences; TRW Building Rm 6D18 3280 Hospital Drive NW Calgary Alberta Canada T2N 4Z6
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Stewart MJ, Kutcher M, Storr M, Seow CH. Interventions for maintenance of mucosal healing in ulcerative colitis. Hippokratia 2014. [DOI: 10.1002/14651858.cd010998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Ulcerative colitis (UC) is a chronic, relapsing, and remitting inflammatory disease involving the large intestine (colon). Treatment seeks to break recurrent inflammation episodes by inducing and maintaining remission. Historically, oral systemic corticosteroids played an important role in inducing remission of this chronic disease; however, their long-term use is limited and can lead to adverse events. Budesonide is a synthetic steroid with potent local anti-inflammatory effects and low systemic bioavailability due to high first-pass hepatic metabolism. Several studies have demonstrated oral budesonide’s usefulness in treating active mild to moderate ileocecal Crohn’s disease and microscopic colitis and in an enema formulation for left sided UC. However, there is limited information regarding oral budesonide’s efficacy in UC. A novel oral budesonide formulation using a multimatrix system (budesonide-MMX) to extend drug release throughout the colon has been developed recently and seems to be an effective treatment in active left sided UC patients. This article summarizes budesonide’s long-term safety and efficacy in treating UC.
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Affiliation(s)
- Marisa Iborra
- Gastroenterology Unit, Department of Digestive Disease, Centro de investigación biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Diego Alvarez-Sotomayor
- Gastroenterology Unit, Department of Digestive Disease, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Pilar Nos
- Gastroenterology Unit, Department of Digestive Disease, Centro de investigación biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), La Fe University and Polytechnic Hospital, Valencia, Spain
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Abstract
INTRODUCTION Budesonide , a synthetic, non-halogenated corticosteroid, has been introduced in the topical treatment of ulcerative colitis (UC). Budesonide MMX, a novel, once-daily oral formulation of budesonide that uses a multi-matrix system (MMX) technology to extend the release of budesonide throughout the colon proved to be effective for the treatment of active UC. The focus of this review is the current status of budesonide MMX in extensive and left-sided UC. AREAS COVERED This paper covers the recent studies of budesonide MMX to describe its efficacy and safety in the treatment of mild-to-moderately active left-sided UC. A literature search and review of budesonide MMX were carried out using the PubMed database up to August 2013. EXPERT OPINION Clinical studies of budesonide MMX in adults with mild-to-moderately active UC demonstrated its efficacy and tolerability in achieving clinical and endoscopic remission. Although one trial is still ongoing, budesonide MMX 9 mg tablets represented the first orally administered topical corticosteroid formulation targeting the entire colon for the management of patients with active, mild-to-moderate UC.
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Affiliation(s)
- Klaudia Farkas
- University of Szeged, First Department of Medicine , 8-10 Koranyifasor, Szeged, H6720 , Hungary
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Abstract
Inflammatory bowel diseases (IBDs) are a group of inflammatory conditions characterized by chronic, uncontrolled inflammation of the gastrointestinal tract. Reported prevalence is high in the United States and northern Europe, while the incidence varies greatly across the rest of Europe. Glucocorticosteroids are the standard treatment for IBD, but due to adverse events their use can be limited. However, new formulations of glucocorticosteroids have been developed to reduce systemic activation. The aim of this review was to assess and summarize the efficacy and safety of new formulations of glucocorticosteroids. A MEDLINE search identified publications focused on new formulations of nonsystemic steroid-based drugs for IBD and benefits and limitations of each of the new glucocorticosteroid formulations were identified. Budesonide has good efficacy and is an established treatment for Crohn's disease; it has been shown to be beneficial for the induction of remission in these patients, although it is not recommended for the maintenance of induced remission. Glucocorticosteroids are not recommended for the maintenance of remission in patients with IBD. However, a recent study suggested that beclomethasone dipropionate may be effective for prolonged treatment in patients in the postacute phase of Crohn's disease who were treated with a short course of systemic steroids. The efficacy of fluticasone propionate and prednisolone metasulphobenzoate in IBD is not well established given the small number of patients enrolled in the few published clinical trials. While the tolerability of these glucocorticosteroids is favourable, more research comparing these new agents with traditional systemic glucocorticosteroids is warranted.
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Affiliation(s)
- Cosimo Prantera
- Azienda Ospedaliera San Camillo Forlanini, via Monterosi 116, 00191 Rome, Italy
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Abstract
It is becoming increasingly recognized that purely clinical endpoints may not be sufficient in the treatment of patients with inflammatory bowel disease. As such, mucosal disease assessment has become a prominent component of the majority of recent clinical trials in Crohn's disease and ulcerative colitis. There is mounting evidence that the attainment of mucosal healing leads to improved clinical outcomes in both Crohn's disease and ulcerative colitis. However, the use of mucosal healing as a therapeutic endpoint in inflammatory bowel disease is in its early stages, as a number of issues limit its application to routine clinical practice.
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Abstract
Topical therapy with mesalazine and/or corticosteroids is the standard treatment for patients with distal ulcerative colitis. Rectal mesalazine is more effective than rectal systemically active corticosteroids or topically active corticosteroids like budesonide. In patients with mild to moderately active distal ulcerative colitis, topical mesalazine is therefore the treatment of choice. Doses of 1 g or higher are equally effective. The period of treatment is important (4 weeks are more effective than 2 weeks). In the case of nonresponse or nontolerability of rectal mesalazine, rectal budesonide is indicated. The standard dose of budesonide is 2 mg/day. This does not usually induce any corticosteroid-associated adverse events. Treatment with rectal mesalazine plus rectal topically active corticosteroids is even more effective than treatment with either substance alone. To overcome adherence problems with rectal therapy, rectal foam preparations have been developed which are usually better tolerated than enemas.
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Affiliation(s)
- Volker Gross
- Medizinische Klinik II, Klinikum St. Marien, Amberg, Deutschland. gross.volker @ klinikum-amberg.de
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Abstract
Budesonide is a synthetic steroid of the glucocorticoid family with a high topical anti-inflammatory activity. Enteric-coated formulations resist gastric-acid degradation, delivering active drug to the small intestine and proximal colon. Budesonide has a high first-pass metabolism with minimal systemic absorption. It is therefore felt to cause fewer side effects than traditional glucocorticosteroids and to be generally well tolerated. The aim of this paper is to examine the utility of this medication in frequently encountered gastrointestinal conditions: Crohn's disease, ulcerative colitis, microscopic colitis and eosinophilic oesophagitis. A Medline search was performed to find published original research and review articles relating to the use budesonide in common gastroenterological conditions. The results showed that budesonide is efficacious in the induction and short-term maintenance of Crohn's disease. Budesonide is the best-documented treatment for microscopic colitis. It is well proven to be effective in the induction of remission in collagenous colitis but its use in lymphocytic colitis remains less well documented. In conclusion, budesonide is an effective glucocorticosteroid therapy for many chronic gastrointestinal diseases. In combination with its efficacy, the low incidence of serious side effects associated with this drug should keep it at the forefront in the therapeutic arsenal of any gastroenterologist.
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Affiliation(s)
- Sarah O'Donnell
- Colm A. O'Morain, DSc (University of London), DSc Honoris Causa (University of Athens), MSc, MD, MA, Dip. Imm., FACG, FEBG, FRCP, FRCPI, FTCD, AGAF, Consultant Gastroenterologist, Professor of Medicine, Dean of Health Sciences Department of Gastroenterology, AMNCH/Trinity College Dublin, Dublin, Ireland
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Römkens TEH, Kampschreur MT, Drenth JPH, van Oijen MGH, de Jong DJ. High mucosal healing rates in 5-ASA-treated ulcerative colitis patients: results of a meta-analysis of clinical trials. Inflamm Bowel Dis 2012; 18:2190-8. [PMID: 22419617 DOI: 10.1002/ibd.22939] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 02/14/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recently, mucosal healing (MH) is regarded as an important treatment goal in ulcerative colitis (UC). 5-Aminosalicylates (5-ASA) are the standard treatment in mild-to-moderate UC, but the effect on MH is less known. The aim of this study was to systematically review the medical literature in order to compare different preparations of 5-ASA for the effect on MH. METHODS We conducted a structured search of PubMed and the Cochrane Central Register of Controlled Trials to identify randomized controlled clinical trials with 5-ASA in UC providing data about MH. We calculated the sample size-weighted pooled proportion of patients with MH, and performed meta-analysis of head-to-head comparisons. RESULTS Out of 645 hits, we included 90 treatment arms, involving 3977 patients using oral 5-ASA (granulate and tablets) and 2513 patients using rectal 5-ASA (suppositories, enema, and foam). Overall, 43,7% of 5-ASA treated patients achieved MH (oral 36,9%; rectal 50,3%). In oral studies, 49% of patients using granulate (7 treatment-arms) achieved MH compared to 34,9% using tablets (43 treatment-arms). In rectal studies the proportion of MH was 62% for suppositories (eight treatment arms), 51% for foam (nine treatment arms), and 46% for enema (23 treatment arms), respectively. CONCLUSIONS 5-ASA preparations achieved MH in nearly 50% of UC patients. There were no significant differences in MH between the various 5-ASA agents, either in the oral or the rectal treatment groups.
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Affiliation(s)
- Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease characterized by diffuse mucosal inflammation limited to the colon and rectum. Although a complete medical cure may not be possible, UC can be treated with medications that induce and maintain remission. The medical management of this disease continues to evolve with a goal to avoid colectomy and ultimately alter the natural history of UC. Emergence of antitumor necrosis factor-α (TNF-α) agents has expanded the medical armamentarium. 5-Aminosalicylates continue to be used in mild to moderate UC and corticosteroids are mainly used for induction of remission with immunomodulators (6-mercaptopurine/azathiopurine/methotrexate) being applied as steroid-sparing agents for maintenance therapy. Infliximab has been approved by the U.S. Food and Drug Administration and used in the treatment of moderate to severe UC; nevertheless, its use may be associated with significant adverse effects and have a negative impact on the postoperative course should the patients undergo restorative proctocolectomy. In addition, there is always a concern about patients' compliance to medical therapy, cost of medications, and risk for UC-associated dysplasia. The authors discuss the pros and cons of medications used in the treatment of UC.
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Affiliation(s)
- Udayakumar Navaneethan
- Center for Inflammatory Bowel Disease, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. USA
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Harris MS, Lichtenstein GR. Review article: delivery and efficacy of topical 5-aminosalicylic acid (mesalazine) therapy in the treatment of ulcerative colitis. Aliment Pharmacol Ther 2011; 33:996-1009. [PMID: 21385194 DOI: 10.1111/j.1365-2036.2011.04619.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The use of topical therapy in the treatment of ulcerative colitis has declined in recent years despite evidence of good efficacy. AIMS To review US prescription trends for 5-aminosalicylic acid (5-ASA) since the US approval of Asacol extended-release oral mesalazine (mesalamine) in 1992; to estimate the optimal level of 5-ASA exposure in the distal colon; to determine factors influencing distal colonic exposures; and to compare the effectiveness of different 5-ASA formulations (oral, topical suspension, foam, suppositories) in clinical trials. METHODS Review of clinical trials, physiologic studies and prescription trends of various mesalazine formulations for treatment of distal ulcerative colitis. RESULTS Between 1992 and 2009, prescriptions for oral mesalazine increased sixfold, whereas topical suspensions declined by 10%. In clinical trials, topical therapy resulted in higher remission and clinical response rates than oral therapy, with trends to earlier improvement. The mucosal concentrations of 5-ASA achieved by topical agents in the distal colon were up to 200-fold higher than those achieved by oral administration alone. Despite active colitis, over 40% of a topically administered 4 g 5-ASA suspension (equal to 1.6 g) reached the sigmoid colon. This likely represents a therapeutic exposure of 5-ASA. Although topical therapies are less convenient than oral medications, treatment algorithms have failed to take into account quality of life improvements resulting from more rapid and complete treatment response. CONCLUSIONS Topical mesalazine therapy is superior to oral therapy in distal ulcerative colitis for both therapeutic response and drug delivery. Practice patterns should be re-evaluated in light of this information.
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Affiliation(s)
- M S Harris
- Division of Gastroenterology, Georgetown University School of Medicine, Washington, DC, USA.
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Gross V, Bunganic I, Belousova EA, Mikhailova TL, Kupcinskas L, Kiudelis G, Tulassay Z, Gabalec L, Dorofeyev AE, Derova J, Dilger K, Greinwald R, Mueller R. 3g mesalazine granules are superior to 9mg budesonide for achieving remission in active ulcerative colitis: a double-blind, double-dummy, randomised trial. J Crohns Colitis 2011; 5:129-38. [PMID: 21453882 DOI: 10.1016/j.crohns.2010.11.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/16/2010] [Accepted: 11/17/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Budesonide may be an effective therapy for mild-to-moderately active ulcerative colitis (UC). This study aimed to demonstrate non-inferiority for oral 9mg budesonide once daily (OD) versus 3g mesalazine granules OD. METHODS This was an eight-week randomised, double-blind, double-dummy, multicentre study in which patients with mild-to-moderately active UC, defined as Clinical Activity Index (CAI) ≥6 and Endoscopic Index (EI) ≥4, received budesonide (Budenofalk® 3mg capsules×3) or mesalazine (Salofalk® 1000mg granules×3). The primary endpoint was clinical remission at week 8 (CAI ≤4 with stool frequency and rectal bleeding subscores of "0"). RESULTS 343 patients were randomised (177 budesonide, 166 mesalazine). Fewer patients achieved the primary endpoint with budesonide versus mesalazine (70/177 [39.5%] versus 91/166 [54.8%]) with a difference in proportions of -15.3% (95% CI [-25.7%, -4.8%]; p=0.520 for non-inferiority). The median time to first resolution of symptoms was 14.0 days (budesonide) and 11.0 days (mesalazine) (hazard ratio 1.19; 95% CI [0.94, 1.51]). Mucosal healing was observed in 54/177 (30.5%) budesonide patients versus 65/166 (39.2%) mesalazine patients, a difference of -8.6% (95% CI [-18.7%, 1.4%]; p=0.093). The incidences of adverse events (budesonide 26.6%, mesalazine 25.3%) and serious adverse events (budesonide 1.7%, mesalazine 1.2%) were similar. CONCLUSIONS Once-daily 3g mesalazine administered as granules is superior to 9mg budesonide OD administered as capsules for achieving remission in mild-to-moderately active UC. However, it is noteworthy that remission of UC was attained in about 40% of budesonide-treated patients with a rapid onset of resolution.
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Affiliation(s)
- Volker Gross
- Medizinische Klinik II, Klinikum St. Marien, Mariahilfbergweg 5-7, 92224 Amberg, Germany.
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Abstract
Rectally administered topical agents have demonstrated efficacy in the maintenance of distal colitis (DC) and proctitis and as they are rarely associated with significant blood drug levels, side effects are infrequent. The topical 5-aminosalicylic acid (5-ASA) suppositories and enemas target different regions of the distal colon and are effective for proctitis and DC, respectively. They demonstrate clinical results that are better than oral 5-ASAs and are preferred to topical steroids with better clinical, endoscopic and histological outcomes, without the risk of adrenal suppression. Disease resistant to topical agents, however, can be extremely difficult to manage. The addition of oral 5ASAs, steroids, immunosuppressants and the anti-tumor necrosis factor-α agents may be effective, but can result in significant side effects and not all patients will respond to the therapies. It is for these patients that new and novel therapies are required. Novel topical agents have been proposed for the management of resistant DC. These agents included butyrate, cyclosporine, and nicotine enemas, as well as tacrolimus suppositories, and tacrolimus, ecabet sodium, arsenic, lidocaine, bismuth, rebamipide and thromboxane enemas. While some of these agents appear to demonstrate impressive outcomes, the majority have only been examined in small open-labeled studies. There is thus a desperate need for more randomized double-blinded placebo controlled studies to investigate the clinical utility of these topical therapies. This review summarizes the efficacy of the established topical therapies, and explores the available data on the new and novel topical agents for the management of DC and proctitis.
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Affiliation(s)
- Ian Craig Lawrance
- Centre for Inflammatory Bowel Diseases, Department of Gastroenterology, Fremantle Hospital, Fremantle, Western Australia, Australia.
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Hartmann F, Stein J. Clinical trial: controlled, open, randomized multicentre study comparing the effects of treatment on quality of life, safety and efficacy of budesonide or mesalazine enemas in active left-sided ulcerative colitis. Aliment Pharmacol Ther 2010; 32:368-76. [PMID: 20491741 DOI: 10.1111/j.1365-2036.2010.04354.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Therapy for active left-sided ulcerative colitis usually involves topical application of mesalazine (mesalamine) or budesonide. AIM To compare the efficacy and safety of budesonide enema and mesalazine enema in the treatment of active left-sided ulcerative colitis. METHODS A total of 237 patients with mild-moderate ulcerative colitis were randomized open 1:1 to receive either budesonide (n = 118) or mesalazine enemas (n = 119) for 8 weeks. Efficacy variables were clinical activity index, endoscopic, histological index and IBDQ scores after 4 and 8 weeks. RESULTS Clinical remission (intention-to-treat analysis) at week 4 was 63.5% for budesonide enemas and 77.2% for mesalazine enemas (P < 0.05). The respective values for the per protocol population (PP) were 59.9% examined in the budesonide group and 77.5% in the mesalazine group (P < 0.02). At the final visit (W8), clinical remission was diagnosed in the ITT analysis for 64.4% of the budesonide group and 77.4% of the mesalazine group (P < 0.05). The respective values for the PP analysis were 59.5% in the budesonide group and 75.3% in the mesalazine group (P < 0.02). CONCLUSIONS Compared with budesonide, mesalazine enema was associated with a significantly higher remission rate; this was supported by favourable trends in endoscopic, histological remission rates and the IBDQ score.
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Abstract
Inflammatory bowel disease (IBD), which comprises two main types, namely, Crohn's disease and ulcerative colitis, affects approximately 3.6 million people in the USA and Europe, and an alarming rise in low-incidence areas, such as Asia, is currently being observed. In the last decade, spontaneous mutations in a diversity of genes have been identified, and these have helped to elucidate pathways that can lead to IBD. Animal studies have also increased our knowledge of the pathological dialogue between the intestinal microbiota and components of the innate and adaptive immune systems misdirecting the immune system to attack the colon. Present-day medical therapy of IBD consists of salicylates, corticosteroids, immunosuppressants and immunomodulators. However, their use may result in severe side effects and complications, such as an increased rate of malignancies or infectious diseases. In clinical practice, there is still a high frequency of incomplete or absent response to medical therapy, indicating a compelling need for new therapeutic strategies. This review summarizes current epidemiology, pathogenesis and diagnostic strategies in IBD. It also provides insight in today's differentiated clinical therapy and describes mechanisms of promising future medicinal approaches.
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Romano C, Famiani A, Comito D, Rossi P, Raffa V, Fries W. Oral beclomethasone dipropionate in pediatric active ulcerative colitis: a comparison trial with mesalazine. J Pediatr Gastroenterol Nutr 2010; 50:385-9. [PMID: 20179636 DOI: 10.1097/MPG.0b013e3181bb3457] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the clinical efficacy of oral beclomethasone diproprionate (BDP) in inducing clinical and endoscopic remission in children with mild to moderate active ulcerative colitis (UC). PATIENTS AND METHODS Thirty patients with active UC (pancolitis or left-sided colitis) were enrolled in an open-labeled, randomized, head-to-head study. Group 1 (n = 15) received oral BDP (5 mg/day) for 8 weeks, followed by maintenance therapy with oral mesalazine, 5-aminosalycilate (5-ASA); group 2 (n = 15) received oral 5-ASA (80 mg . kg . day). Assessments were carried out (at 4, 8, and 12 weeks) for clinical scores and for endoscopy (at 12 weeks), together with a final clinical assessment after 1 year follow-up. RESULTS Patients treated with BDP showed a significant reduced clinical activity within 4 weeks (P < 0.001 vs pretreatment values) with 80% achieving clinical remission compared with 33% treated with only 5-ASA (P < 0.025). A significant reduction in clinical activity was achieved by 5-ASA after 8 weeks. Comparing clinical activity between BDP and 5-ASA, the former did significantly better at 8 (P < 0.003) and at 12 weeks (P < 0.015). In 73% of BDP-treated patients colonoscopy showed remission compared with 27% of 5-ASA (P < 0.025). Both treatments led to better scores compared with pretreatment values (P < 0.001, both). Erythrocyte sedimentation rate was significantly reduced (P < 0.025 or less) with both treatments, whereas C-reactive protein dropped significantly (P < 0.02) only in BDP. CONCLUSIONS Oral BDP was well tolerated and acts significantly faster and more effectively than 5-ASA in inducing clinical remission and endoscopic improvement in pediatric mild-to-moderate UC.
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Abstract
BACKGROUND 5-Aminosalicylates (5-ASA) are considered a first-line therapy for inducing and maintaining remission of mild to moderately active ulcerative colitis (UC). When inflammation in UC is limited to the distal colon, 5-ASA can also be administered rectally as a suppository, enema or foam. OBJECTIVES A systematic review was undertaken to evaluate the efficacy of rectal 5-ASA for treating active distal UC. SEARCH STRATEGY Electronic searches of the MEDLINE database (1966-2008), the Cochrane Central Register of Controlled Trials and the Cochrane IBD/FBD Group Specialized Trials Register were supplemented by manual reviews of reference listings and conference proceedings. SELECTION CRITERIA Randomized trials comparing rectal 5-ASA to placebo or another active therapy were eligible for inclusion. Eligible trials enrolled patients with a distal disease margin less than 60 cm from the anal verge or distal to the splenic flexure. Trials that enrolled subjects less than 12 years of age were excluded. DATA COLLECTION AND ANALYSIS Eligibility was assessed by three authors. Data were extracted by two authors using standardized forms. Pooled odds ratios (POR) for inducing improvement and remission by symptomatic, endoscopic and histologic criteria were calculated using an intention to treat principle. Fixed effects models were used unless heterogeneity was encountered within groups (P < 0.10), where random effects models were used. All statistical analyses were performed using RevMan 5. Where sufficient data were available, subgroup analyses were performed for disease extent, total daily 5-ASA dose, 5-ASA formulation (enema,suppository, foam) and the type of control intervention (placebo or another active therapy). MAIN RESULTS Thirty-eight studies fulfilled the inclusion criteria. Rectal 5-ASA was superior to placebo for inducing symptomatic, endoscopic and histological improvement and remission, with POR for symptomatic improvement 8.87 (8 trials, 95% CI: 5.30 to 14.83; P < 0.00001), endoscopic improvement 11.18 (5 trials, 95% CI 5.99 to 20.88; P < 0.00001), histologic improvement 7.69 (6 trials, 95% CI 3.26 to 18.12; P < 0.00001), symptomatic remission 8.30 (8 trials, 95% CI 4.28 to 16.12; P < 0.00001), endoscopic remission 5.31 (7 trials, 95% CI 3.15 to 8.92; P < 0.00001), and histologic remission 6.28 (5 trials, 95% CI 2.74 to 14.40; P < 0.0001). Rectal 5-ASA was superior to rectal corticosteroids for inducing symptomatic improvement and remission with POR 1.56 (6 trials, 95% CI 1.15 to 2.11; P = 0.004) and 1.65 (6 trials, 95% CI 1.11 to 2.45; P = 0.01), respectively. Rectal 5-ASA was not superior to oral 5-ASA for symptomatic improvement (POR 2.25; 95% CI 0.53 to 19.54; P = 0.27). Neither total daily dose nor 5-ASA formulation affected treatment response. AUTHORS' CONCLUSIONS Rectal 5-ASA should be considered a first-line therapy for patients with mild to moderately active distal UC. The optimal total daily dose and dose frequency of 5-ASA remain to be determined. Future research should define differences in efficacy among patient subgroups defined by proximal disease margin and disease activity. There is a strong need for consensus standardization of outcome measurements for clinical trials in ulcerative colitis.
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Affiliation(s)
- John K Marshall
- Division of Gastroenterology, McMaster University, 1200 Main Street 2F59, Hamilton, Ontario, Canada, L8N 3Z5
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Abstract
Mucosal healing (MH) has emerged as an important treatment goal for patients with IBD. Historically, the therapeutic goals of induction and maintenance of clinical remission seemed insufficient to change the natural history of IBD. Evidence has now accumulated to show that MH can alter the course of IBD, as it is associated with sustained clinical remission, and reduced rates of hospitalization and surgical resection. In patients with ulcerative colitis, MH may represent the ultimate therapeutic goal because inflammation is limited to the mucosa. In patients with Crohn's disease, which is a transmural disease, MH could be considered as a minimum therapeutic goal. This Review focuses on the definition of MH and discusses the ability of each available IBD medication to induce and maintain MH. The importance of achieving MH is also discussed and literature that demonstrates improvement of disease course with MH is reviewed. Finally, we discuss how best to integrate the treatment end point of MH into clinical practice for the management of patients with IBD.
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Affiliation(s)
- Guillaume Pineton de Chambrun
- Clinique des maladies de l'appareil digestif et de la nutrition, Hôpital Claude Huriez, Rue Michel Polonovski, 59037 Lille Cedex, France
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Abstract
BACKGROUND Ulcerative proctitis (UP) is a common presentation of ulcerative colitis (UC). OBJECTIVE To summarize available literature on up-to-date management and pharmacotherapy of UP patients. METHODS Extensive Medline/Embase literature search was performed to identify relevant articles. RESULTS/CONCLUSION Topical medication with rectally administered 5-aminosalicylic acid (5-ASA)/corticosteroid suppositories or enemas is effective treatment for most UP patients. Locally administered 5-ASA is more efficacious than oral compounds. The combination of topical 5-ASA and oral 5-ASA or topical steroids should be considered for escalation of treatment. Maintenance treatment is indicated in all UC cases. 5-ASA suppositories are suggested as first-line maintenance therapy if accepted by patients, although oral 5-ASA as maintenance therapy might prevent proximal extension of the disease. After re-assessment, chronically active patients refractory or intolerant to 5-ASAs and corticosteroids may require immunomodulators or biological therapy. Exceptional cases may require a proctocolectomy.
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Affiliation(s)
- Peter Laszlo Lakatos
- Semmelweis University, First Department of Medicine, H1083 Budapest, Koranyi S 2A, Hungary.
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Huang ML, Ran ZH, Tong JL, Lu LH, Xiao SD. Effects of topical administration of budesonide and traditional glucocorticosteroids on active distal ulcerative colitis or proctitis. Shijie Huaren Xiaohua Zazhi 2008; 16:326-331. [DOI: 10.11569/wcjd.v16.i3.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effects of topical administration of budesonide and traditional glucocorticosteroids on distal ulcerative colitis or proctitis and to analyze their efficacy and side effects.
METHODS: Medline, Embase and China Biological Medicine Disc were searched for randomized controlled trials and related articles comparing the effects of topical administration of budesonide and traditional glucocorticosteroids on distal ulcerative colitis or proctitis. Meta-analysis was performed with Review Manager 4.2.8.
RESULTS: Six studies met the inclusion criteria. No significant difference was found in the endoscopic, histological and clinical remission rates for the effects of topical administration of budesonide and traditional glucocorticosteroids on active distal ulcerative colitis or proctitis (OR = 1.21, 95%CI: 0.84-1.74, P > 0.05; OR = 1.08, 95%CI: 0.75-1.57, P > 0.05, OR = 1.09, 95%CI: 0.75-1.58, P > 0.05). However, the effect of topical administration of budesonide on plasma cortisol level was lower than that of conventional glucocorticosteroids. There was a significant difference between them (OR = 0.17, 95%CI: 0.06-0.53, P < 0.05).
CONCLUSION: The effects of budesonide and traditional glucocorticosteroids on active distal ulcerative colitis or proctitis are similar. However, budesonide may be preferable to traditional glucocorticosteroids since its inhibitory effect on plasma cortisol level is lower than glucocorticosteroids.
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Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract. While a cure remains elusive, both can be treated with medications that induce and maintain remission. With the recent advent of therapies that inhibit tumor necrosis factor (TNF) alpha the overlap in medical therapies for UC and CD has become greater. Although 5-ASA agents have been a mainstay in the treatment of both CD and UC, the data for their efficacy in patients with CD, particularly as maintenance therapy, are equivocal. Antibiotics may have a limited role in the treatment of colonic CD. Steroids continue to be the first choice to treat active disease not responsive to other more conservative therapy; non-systemic steroids such as oral and rectal budesonide for ileal and right-sided CD and distal UC respectively are also effective in mild-moderate disease. 6-mercaptopurine (6-MP) and its prodrug azathioprine are steroid-sparing immunomodulators effective in the maintenance of remission of both CD and UC, while methotrexate may be used in both induction and maintenance of CD. Infliximab and adalimumab are anti-TNF agents approved in the US and Europe for the treatment of Crohn's disease, and infliximab is also approved for the treatment of UC.
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Abstract
BACKGROUND Beclomethasone dipropionate (BDP) is a second-generation steroid with topical effects and minimal systemic activity for patients with ulcerative colitis (UC). AIM To review all available literature to assess the efficacy of enema/foam BDP compared with enema/foam 5-aminosalicylic acid (5-ASA) in the control of left-sided mild-moderate UC. METHODS We selected randomized controlled trials of enema/foam BDP compared with enema/foam 5-ASA treatment in patients with UC. Two reviewers assessed trial quality and extracted data independently. RESULTS Four trials involving 428 UC patients, 209 treated with 5-ASA (1-4 g o.d.) and 219 with BDP (3 mg o.d.), were included. Intention-to-treat analysis showed that 5-ASA induced improvement/remission of UC in 146 (69.9%) patients, while BDP in 143 (65.3%). The test for heterogeneity (Cochran Q) was not significant and Mantel-Haenszel pooled estimate of odds ratio was 1.23 (95% CI = 0.82-1.85). The results did not change when analysis was performed on a per-protocol basis. CONCLUSION The randomized controlled trials identified in this review showed that rectal BDP has equal effect as 5-ASA to control symptoms in UC.
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Affiliation(s)
- F Manguso
- Gastroenterology Unit, A. Cardarelli Hospital, Naples, Italy
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