Konservative Therapie der Divertikelkrankheit

Background

The prevalence of diverticulosis is between 28–45% in the general population and by more than 60% for those over 70 years old. A further increase in the hospitalization rate due to complications can be observed. Furthermore, younger patients are now also increasingly suffering from diverticulosis. It is time to question the non-critical use of antibiotic treatment as well as the necessity of surgery. New treatment approaches must be found.

Objective

What significance does conservative treatment, especially antibiotic treatment, have in the treatment of diverticular disease?

Methods

The current literature and the first S2k guidelines on “diverticular disease/diverticulitis” were evaluated.

Results

There are several options in the primary prophylaxis of diverticular disease. A high-fiber, low-meat diet, physical activity and weight management as well as avoiding cigarettes can reduce complications. Avoiding non-steroidal anti-inflammatory drugs (NSAID), corticoids and opioids also reduces the risk of complications. As long as there are no risk factors, the use of antibiotics is not normally necessary in the treatment of acute uncomplicated diverticular disease. Aminosalicylates and non-resorbable antibiotics have not been proven to be effective. The treatment of acute complicated diverticulitis consists of antibiotics, infusion of electrolytes and, if necessary abscess drainage or surgery.

Conclusion

The indications and correct selection of conservative treatment has to be determined by evaluation of the stage of diverticular disease, the physical condition and the patient’s risk factors. Antibiotic treatment is ultimately only one part of the conservative management.

     

NASH und Hepatitis C

Non-alcoholic fatty liver disease (NAFLD) with development of steatohepatitis (NASH) and chronic hepatitis C virus (HCV) infection are the most frequent causes of chronic liver disease and its sequelae. NAFLD has a prevalence of 20–30% in the general population, whereas liver steatosis is observed in 40–80% of patients with chronic hepatitis C. Steatohepatitis in patients with chronic hepatitis C is associated with viral factors, such as genotype 3 infection and with diabetes mellitus and obesity as host factors. HCV has been shown to cause liver steatosis by direct and indirect interference with cellular signal transduction pathways. Liver steatosis in patients with chronic hepatitis C is clinically relevant because of its association with an increased risk for liver cirrhosis, hepatocellular carcinoma and failure to respond to interferon-based antiviral therapy in genotype non-3 infected patients. Treatment of liver steatosis in patients with chronic hepatitis C should aim at viral eradication and treatment of obesity, insulin resistance and diabetes mellitus.     

Neue direkt antivirale Medikamente zur Behandlung der chronischen Hepatitis C 2014

Background

The development of direct-acting antiviral agents (DAA) against the hepatitis C virus (HCV) has seen enormous progress in recent years. In 2011, the first protease inhibitors boceprevir (BOC) and telaprevir (TLV) were approved, which still need to be combined with pegylated interferon α (PEG-IFN α) and ribavirin (RBV) and are used only in patients with genotype 1. With sofosbuvir (SOF) and simeprevir (SMV), two new DAA are available. More DAA are in clinical development.

Objectives

Which changes in the treatment of chronic hepatitis C infection can be expected with the approval of the new DAA in 2014? Relevant phase IIb and phase III studies for the approval in 2014 were considered for drugs approved by the FDA or EMA at the editorial deadline.

Current data

For patients with genotype 1, the combination of SOF, SMV or faldaprevir with PEG-IFN α and RBV was successfully evaluated in phase III studies. In contrast to previous treatment with PEG-IFN α, RBV and telaprevir (TLV) or boceprevir (BOC), therapy can be shortened in most cases with a significantly improved side-effect profile. Cure rates above 80?% are possible. Data are also available for an interferon-free therapy with either SOF and RBV or SOF and SMV in GT-1 patients. SVR rates exceeding 60?% and up to 90?% are possible. However, treatment experience with these combinations is low and an unrestricted interferon-free therapy for genotype 1 should not be expected before 2015. For patients with genotypes 2 and 3, valid data for interferon-free therapies are available. The combination of SOF and RBV for 12 weeks in genotype 2 and 24 weeks for genotype 3 is effective and shows equal or superior cure rates with fewer side effects than the PEG-IFN α/RBV therapy.

Conclusion

For patients with genotype 1, the duration of therapy can be further reduced with better side effect profile. In certain situations, therapy without PEG-IFN α is possible and should be considered. For patients with genotypes 2 and 3, an interferon-free therapy will be standard of care in 2014.     

Hepatitis C core antigen highly correlated to HCV RNA

Hepatitis C virus core antigen (HCV-Ag) immunoassay has been proposed as a more cost and time efficient one-step alternative to the current two-step screening and diagnostic process. This study investigates the correlation between the HCV-Ag immunoassay and the current gold standard of Hepatitis C Virus (HCV) ribonucleic acid (RNA) molecular assay. Stored sera of 221 consecutive treatment-naive patients tested anti-HCV positive were selected to undergo both HCV-Ag immunoassay and HCV RNA molecular assay. Active infection status and HCV genotype were determined using both assays, and correlation was calculated using a logarithmic scale. Among 221 anti-HCV-positive sera, 197 were positive for both HCV Ag (≥3 fmol/L) and HCV RNA (>15 IU/mL), 22 were negative for both tests, while 2 were positive to HCV RNA only. The sensitivity and specificity for HCV Ag in predicting HCV RNA were 99% and 100%, respectively. Out of 199 patients (90%) tested positive for HCV viremia, 107 (56%) were of genotype 1, 77 (38.7%) of genotype 2 and 15 of other genotypes. Analysis of 221 anti-HCV-positive patient sera found a strong positive correlation between HCV RNA and HCV-Ag (r = 0.960, p < 0.001). Genotype 1 (log [HCV RNA] = 0.988 x log [HCV-Ag] + 2.768), with correlation coefficient 0.945, exhibited a stronger correlation than genotype 2 (log [HCV RNA] = 0.859 x log [HCV-Ag] + 2.859; r = 0.862). Given the strong positive correlation between HCV-Ag immunoassay and HCV RNA molecular assay in genotyping affected individuals, we propose that HCV-Ag immunoassay is a more cost and time efficient alternative to the current two-step diagnostic process.     

Therapie der Reisediarrhö

Along with the dizzying rise in the world's population and economic globalization, travel activity has also increased. Travelers' diarrhea, caused by changed sanitary conditions, has a very different pathogenic spectrum and clinical course from those of our native forms of infectious enterocolitis. Awareness of the warning signs of complications in the clinical course and of the differential diagnoses is therefore a prerequisite for rational therapy. This covers oral rehydration, motility inhibitors, adsorbents, antisecretory agents, probiotics, and last but not least the use of antibiotics, which make an essential contribution if correctly used. There are interesting developments in the form of nonabsorbable antibiotics and new antisecretory agents, which inhibit protein synthesis and enzymes and are increasingly used as antidiarrheal agents with few side effects. In the combination of various therapeutic options in travelers' diarrhea there is still much scope for research. The priority is the correct implementation of the options available today, in order to avoid, as far as possible, therapeutic setbacks and the development of resistance.     

Medikamentöse Therapie der Komplikationen der Leberzirrhose

Patients with liver cirrhosis bear a considerable risk of a variety of complications that involve virtually all organ systems. They can be addressed with a wide spectrum of drugs for acute interventions as well as for prophylactic purposes. At the same time treatment of the underlying disease, the identification and treatment of triggering factors and the possibility of liver transplantation should be kept in mind.     

Medikamentöse Therapie der Harninkontinenz

Urinary incontinence has a high prevalence in both men and women. Women suffer predominantly from stress urinary incontinence and men from urge incontinence. Other types of incontinence are less frequent. Stress urinary incontinence is caused by an insufficient urethral closure mechanism and urge incontinence by uninhibited detrusor contractions. Medical treatment is beside other conservative options and operations only one part of the treatment strategy in incontinence. Duloxetine, a serotonine-norepinephrine reuptake inhibitor, is used to treat stress urinary incontinence, can increase activity of the external urethral sphincter and is able to reduce incontinence episodes in up to 64%. Antagonists of muscarinic receptors can reduce urgency, frequency and urge incontinence as well as increase bladder capacity significantly. In Germany, trospium chloride, tolterodine, solifenacin, oxybutynin and propiverine are available to treat urge incontinence. Efficacy of these agents are comparable. However, tolerability is different and side effects, especially dry mouth, often limit their use. None of the agents show ideal efficacy or tolerability in all patients and, therefore, new agents and formulations are currently under clinical investigation.     

Nichtmedikament?se Therapie der Adipositas

Hintergrund: Die heutige Adipositas-"Epidemie" ist in erster Linie eine Folge der modernen Lebensweise mit überkalorischer, vor allem zu fettreicher Ernährung und Bewegungsmangel. Basistherapieprogramm: Im Sinne einer pathogenetisch orientierten Therapie ergibt sich daraus die Forderung nach einer langfristigen Lebensstiländerung. Ein solches Basistherapieprogramm sollte eine Ernährungsumstellung hin zu einer fettreduzierten, ballaststoffreichen Kost, eine Steigerung der körperlichen Bewegung und Verhaltensmodifikationselemente umfassen. Dieses integrierte Therapiekonzept zielt auf eine initiale Gewichtssenkung von 5-10%, aber auch auf eine langfristige Gewichtskontrolle. Background: The current epidemic of obesity is primarily a consequence of the modern lifestyle characterized by a hypercaloric, high-fat diet and lack of physical activity. Integrated Treatment Concept: In order to establish a treatment strategy oriented at the pathogenesis of the disorder it is necessary to strive for a long-term change in lifestyle. The modern best-practice treatment of obesity includes a healthy, low-fat diet, an increase in physical activity and behavior modification. This integrated treatment concept aims at decreasing body weight by 5-19% and at obtaining long-term weight management.     

Therapie der venösen Thromboembolie

The main objectives in the treatment of venous thromboembolism are to prevent clot extension and pulmonary embolism, to reduce mortality and to prevent recurrent thromboembolic events as well as postthrombotic disorders. Initial and effective anticoagulation with heparin, preferably with low molecular weight heparin (LMWH), or with fondaparinux is the most important measure. Unfractioned heparin (UFH) is as effective as LMWH, but requires coagulation-monitoring and is associated with a higher risk of heparin-induced thrombocytopenia. In patients with renal insufficiency direct determination of anti-factor Xa activity and dose adjustment is recommended, since drug accumulation can occur over time. In those patients UFH instead of LMWH might be favored. Long-term treatment should be administered with vitamin K-antagonists (INR-target range 2–3) for a duration of 3 to 6 months. In case of recurrent venous thromboembolism, indefinite therapy is recommended. Additional treatment with compression stockings is reasonable. Patients who do not require hospital treatment for other conditions, who have a low bleeding risk, no excessive venous congestion and no symptomatic pulmonary embolism can safely be treated at home. In most cases bed rest is not necessary. Thrombolysis or surgical thrombectomy is seldomly indicated in severe thromboembolism.     

Therapie der sekundären Arthropathien

Arthralgia is one of the most common complaints in Western society. The classification of joint diseases with respect to genesis is crucial for the determination of adequate treatment. For inflammatory arthropathies, treatment options have expanded significantly over the last decade. This review summarizes the current treatment of psoriatic arthritis and Reiter's disease, both belonging to the spectrum of seronegative spondyloarthropathies. Regardless of our increasing knowledge of chondrogenesis, the treatment of osteoarthritis is still more or less symptomatic. Premature age of onset and the atypical joint distribution of osteoarthritis should bring metabolic diseases, for example hemochromatosis, into consideration.