Enteral nutrition effective for inducing remission in pediatric Crohn's disease

Reuters Health Information: Enteral nutrition effective for inducing remission in pediatric Crohn's disease

Enteral nutrition effective for inducing remission in pediatric Crohn's disease

Last Updated: 2017-08-31

By Will Boggs MD

NEW YORK (Reuters Health) - Exclusive enteral nutrition is as effective as corticosteroids for inducing remission in pediatric Crohn's disease and may be better for achieving mucosal healing, according to a meta-analysis.

"Rather than alter management, our work should bring greater consensus," Dr. Arun Swaminath from Lenox Hill Hospital, Northwell Health, New York, told Reuters Health by email. "There had been some debate in the literature regarding superiority of steroids, but our study took into account only those full manuscripts which could allow us to study their strengths and weaknesses. So the most complete data was what was used to reach the conclusions of the meta-analysis."

Corticosteroids, the most commonly used medications in the U.S. to induce remission in Crohn's disease, are associated with growth retardation, low bone mineral density, adrenal suppression, and body-image dissatisfaction in the pediatric population. Exclusive enteral nutrition (EEN) is frequently used in Europe, but fewer than 4% of pediatric gastroenterologists in North America use it.

In their analysis, Dr. Swaminath's team ultimately focused on 8 studies, involving 451 patients, comparing the efficacy of corticosteroids versus EEN. The paper was published online August 16 in Alimentary Pharmacology and Therapeutics.

Rates of induction of remission did not differ significantly between EEN and corticosteroid recipients who had newly diagnosed or relapsed disease. This finding persisted when analyses were limited to newly diagnosed patients or to relapsed patients - and when the analysis focused on 5 studies that used a polymeric formula in the enteral nutrition arm.

EEN-treated patients tended to remain in remission longer than those treated with corticosteroids, but the difference fell short of statistical significance. The two groups also did not differ significantly in C-reactive protein (CRP) normalization rates.

In an exploratory analysis, EEN recipients were 4.5 times more likely than those who received corticosteroids to exhibit mucosal healing.

"If the mucosa of the colon improves from an inflamed ulcerated surface to one that is nearly (or completely) normal, these patients have the best chance of avoiding flares and complications long term," Dr. Swaminath said by email. "While there were only 2 studies (of quite different methodology) that had data on this endpoint, the degree of difference was remarkable. If it's true that mucosal healing is superior in EEN-treated patients, then there will be reason to adopt that as the superior therapy."

"Given these data supporting that EEN in Crohn's induction treatment is worth the effort, we may see its use more widely adopted outside of specialized centers in the U.S., similar to the practice in Canada and Western Europe," he said.

"We studied only pediatric data, and many among us feel that it should work just as well in adults, but that it has not been studied as well or as closely," Dr. Swaminath said. "Poring through the data gave us all an appreciation for how difficult it is to do a diet study in the first place, and then to do it well is altogether another thing! Why substituting EEN for solid food should put Crohn's into remission is still poorly understood."

"It's an exciting time for patients with Crohn's disease because there are so many treatments in the pipeline that have unique mechanisms of action, so as physicians, we have the opportunity to get a vast majority of our patients into a deep remission," he said. "We may need to think about combining EEN with drug therapy, in future trials, to get an even greater treatment effect during induction of remission."

Dr. Amit Assa from Sackler Faculty of Medicine, Tel Aviv University, in Israel, who also recently reviewed EEN for inducing remission in pediatric inflammatory bowel disease, told Reuters Health by email, "Treatment with exclusive liquid diet can achieve a significant benefit when given prior to surgical intervention in Crohn's disease patients and even can prevent surgery in up to 25% of patients. It is still an enigma how EEN results in a much higher mucosal healing when compared with corticosteroid therapy."

"The main message should be that exclusive enteral nutrition with either polymeric or elemental formula should be offered as first line for any child with luminal Crohn's disease," he said. "It should be offered as well to children and adults before an elective intestinal resection due to disease complications."

Dr. Richard Hansen from Royal Hospital for Children, Glasgow, UK, told Reuters Health by email, "The most interesting discussion to make on EEN is why this is a mainstay of therapy in children in Europe, Australasia, and parts of Canada, yet has limited traction in the U.S."

"The data presented are not surprising to me. We've known for a long time that this is an effective therapy for Crohn's disease, and in Glasgow (and most of Europe) it's our first-line treatment for both children with newly diagnosed Crohn's disease and those with a known diagnosis who then flare," he said. "We find it achieves clinical remission in about 4 of 5 cases. We're so committed to this therapy that we have an active research program 'CD-TREAT' looking to develop solid-food diets that can match the efficacy of EEN."

Dr. Hansen added, "I think in the U.S., the main reasons for reduced uptake of this treatment are difficulties negotiating insurance payouts for a nutritional therapy and the high levels of multidisciplinary team support needed for such a treatment - specialist dietitians, IBD nurse specialists, etc."

SOURCE: http://bit.ly/2gqiLP7

Aliment Pharmacol Ther 2017.

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