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1.
Opinion statement Therapeutic options for refractory colonic inflammation in patients with ulcerative colitis or Crohn’s disease have recently
been augmented by the introduction of biologic therapies. Intravenous corticosteroids and cyclosporin A remain the standard
therapies for severe ulcerative colitis. Monoclonal antibodies directed at tumor necrosis factor alfa (TNF-α) have proven
to be most efficacious in patients with severe or refractory Crohn’s disease. Immunomodulatory therapy with azathioprine,
6-mercaptopurine, or methotrexate has demonstrated efficacy for maintenance of remission in patients with refractory ulcerative
colitis or Crohn’s disease. The use of experimental biologic agents may be considered for those patients who fail to respond
to or remain dependent on corticosteroids. Surgical intervention is indicated for patients with severe colitis who fail to
respond to medical therapy or develop life-threatening complications such as perforation or toxic megacolon. 相似文献
2.
Recently, conventional therapies for inflammatory bowel disease (IBD) have not received the same amount of attention as biologic
therapies, yet they remain the backbone of therapy for IBD because of their efficacy, safety, and relatively low cost. Advances
in efficacy and safety continue because of modifications in drug dosing and monitoring. Higher doses of mesalamine per pill,
together with once-daily dosing, may help to optimize drug delivery and patient compliance. Budesonide, an effective agent
for both induction and short-term remission maintenance in Crohn’s disease, is devoid of many of the toxicities common to
corticosteroids. Assessments of thiopurine methyltransferase and metabolite levels are helping to fine-tune dose optimization
for the thiopurines azathioprine and 6-mercaptopurine. The oral calcineurin inhibitors tacrolimus and cyclosporine have been
shown to have expanded roles in IBD, and methotrexate may be useful in some patients with refractory ulcerative colitis. Probiotics
are showing promise for maintenance of remission in Crohn’s disease, ulcerative colitis, and pouchitis. 相似文献
3.
Management of refractory ulcerative colitis 总被引:2,自引:0,他引:2
Opinion statement A physician’s approach to patients with ulcerative colitis (UC) who are refractory to standard first-line therapies must be
thoughtful and systematic and include the individual’s physical and emotional state as the physician examines the various
dietary, medical, and surgical options currently available. It is of foremost importance to confirm that the refractory patient’s
symptoms are not simply due to dietary indiscretion, concomitant bowel infection (especially with Clostridium difficile), an incorrect diagnosis (eg, colitis due to infection, NSAIDs, ischemia, diverticulitis, or Crohn’s disease), or even a
concomitant diagnosis (eg, celiac sprue, pancreatic insufficiency, functional bowel disorder, laxative or sorbitol intake).
The ability to quickly assess the status of the colonic mucosa with flexible sigmoidoscopy aids in the ability to distinguish
patients with refractory inflammation from those with other diagnoses. The initiation and optimization of the long-term purine
analogues azathioprine (AZA) or 6-mercaptopurine (6-MP) remain the backbone of medical therapy for patients with refractory
UC. For those unresponsive to corticosteroids, quicker induction of remission may necessitate infliximab, cyclosporine, or
tacrolimus. Successful induction and maintenance with AZA, 6-MP, and/or infliximab should be followed by long-term therapy
with these agents. Cessation of therapy often leads to relapse. Novel therapies under investigation hold the promise of offering
more options for both the induction and maintenance of remission in refractory UC patients. Discussions of surgical intervention
should not be put off as a last resort but rather included in the overall treatment plan offered to the patient. 相似文献
4.
Approximately 10% to 30% of patients with ulcerative colitis and up to 70% of patients with Crohn’s disease will undergo surgery
at some point during their lifetime. Although patients with ulcerative colitis are considered "cured" by surgery, patients
who have undergone an ileal pouch anal anastomosis may develop pouchitis, cuffitis, pouch irritability, or even Crohn’s disease.
Various therapies have shown success, including probiotics, in the prevention of pouchitis onset or relapse. Crohn’s disease
historically recurs following surgery; prophylaxis against disease recurrence has been attempted with a variety of agents,
with variable success. Innovative therapies holding promise for the future treatment or prevention of these conditions are
under exploration. 相似文献
5.
Opinion statement
相似文献
– | Crohn’s disease and ulcerative colitis remain medically incurable conditions with potentially significant morbidity. The treatment of children with these conditions therefore should seek to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications, and minimize the potential psychologic effects of chronic illness. Treatment strategies must seek to both induce and maintain clinical remission. For all but the most mildly affected children with Crohn’s disease, a combination of nutritional and pharmacologic approaches is optimal. For those with ulcerative colitis, anti-inflammatory medication is necessary. |
– | Moderate to severe Crohn’s disease acutely responds best to potent immunomodulatory therapy, eg, corticosteroids and infliximab. Either agent must be coupled with 6-mercaptopurine or azathioprine to maintain long-term remission and to minimize toxicity. Particular attention must be paid to limit the growth suppression and other toxic effects of corticosteroids. Elemental or semielemental enteral nutrition also can induce remission effectively, but relapse is common after primary nutritional therapy is discontinued, mandating concomitant pharmacologic therapy with either 6-mercaptopurine or azathioprine. The availability of 6-mercaptopurine/azathioprine metabolite testing allows optimization of immunomodulatory therapy, detection of noncompliance, and avoidance of potentially dangerous toxicity. |
– | Mild ulcerative colitis acutely responds to treatment with a 5-aminosalicylate medication. Long-term remission frequently can be maintained with the same medication. Moderate to severe disease activity requires potent immunomodulatory therapy if colectomy is to be avoided. |
– | Surgery is a potential cure for patients with ulcerative colitis, although the development of pouchitis after ileal pouch anal anastomosis is common and frequently requires long-term medical management. Surgery provides only palliative relief of complications in those with Crohn’s disease. |
– | Emerging therapies, especially evolving biologic and probiotic agents, offer hope for better treatments in the years ahead. |
6.
Tremaine WJ 《Current gastroenterology reports》2012,14(2):162-165
About 10% of patients with colitis due to inflammatory bowel disease have indeterminate colitis. Despite newer diagnostic
tools, the frequency has not diminished over the past 33 years. The current preferred term among academicians is colonic inflammatory
bowel disease unclassified (IBDU), although indeterminate colitis is the term endorsed for inclusion in the ICD-10 coding
system. Indeterminate colitis is more frequent among children. The anti-Saccharomyces cerevisiae (ASCA) and perinuclear anti-cytoplasmic
antibody (pANCA) are useful in distinguishing IBDU from ulcerative colitis and Crohn’s disease. However, current serologic
and genetic studies, as well as endoscopic and imaging studies lack sufficient positive predictive values to make a definite
diagnosis of Crohn’s colitis or ulcerative colitis. Patients with IBDU who undergo proctocolectomy with ileal pouch-anal anastomosis
have more complications than patients with ulcerative colitis. Although some patients with indeterminate colitis eventually
develop characteristic ulcerative colitis or Crohn’s disease, a subgroup are durably indeterminate. 相似文献
7.
Traditional medications for inflammatory bowel disease are small molecule drugs, most of which were developed for use in other
diseases before being found to be efficacious for the treatment of ulcerative colitis or Crohn’s disease. Recently, several
exciting alternative approaches to the medical treatment of inflammatory bowel disease have been developed. These include
biologic, probiotic, and apheresis therapies that offer certain advantages over traditional drug therapy for inflammatory
bowel disease. The purpose of this review is to assess the current state of knowledge about novel biologic, probiotic, and
apheresis therapies and to analyze how best to incorporate these therapies into evolving management paradigms of inflammatory
bowel disease. 相似文献
8.
Opinion statement Anti-tumor necrosis factor-α (anti-TNF) therapy has become a very important modality in the treatment of patients with inflammatory
bowel disease. A number of anti-TNF medications have been investigated for this purpose, many via randomized controlled trials.
Infliximab, the most studied of these agents, has shown impressive efficacy in the treatment of luminal and fistulizing Crohn’s
disease, as well as ulcerative colitis. Adalimumab and certolizumab have shown similar efficacy in Crohn’s disease but have
not yet been studied in ulcerative colitis. Less impressive results were seen in randomized controlled trials involving CDP-571,
etanercept, or onercept for patients with Crohn’s disease. Thalidomide and CNI-1493 have been evaluated only preliminarily
in small, open-label pilot studies in patients with Crohn’s disease. The future of anti-TNF therapy in inflammatory bowel
disease is very bright, as exciting new developments continue to be made at a rapid pace. 相似文献
9.
Opinion statement Various biologic agents have been evaluated in patients with inflammatory bowel disease (eg, Crohn’s disease [CD]) and ulcerative
colitis (UC). At present, only one, infliximab (humanized monoclonal anti-tumor necrosis factor-á antibody), is approved by
the US Food and Drug Administration for induction and maintenance treatment in patients with active moderate to severe and/or
fistulizing CD who are refractory to conventional therapy. Two recent trials, Active Ulcerative Colitis Trial (ACT) 1 and
ACT 2, observed high efficacy of infliximab in inducting and maintaining clinical remission, mucosal healing, and corticosteroid-sparing
effects in patients with moderate to severe UC. A plethora of randomized, double-blind, controlled and open-label, uncontrolled
studies on large and small numbers of patients has assessed efficacy and safety of various biologic agents of potential use
in treatment of inflammatory bowel disease. With respect to safety of biologic agents used for treatment, the most accurate
data are available only in the case of infliximab. This is due to the fact that infliximab was evaluated in many more trials
than any other biologic agent. Moreover, postmarketing experience also provides very valuable information about any side effects
occurring during treatment with this agent. 相似文献
10.
Reese GE Lovegrove RE Tilney HS Yamamoto T Heriot AG Fazio VW Tekkis PP 《Diseases of the colon and rectum》2007,50(2):239-250
Purpose This study was designed to compare postoperative adverse events and functional outcomes after ileal pouch-anal anastomosis
between patients with Crohn’s disease and those with non-Crohn’s disease diagnoses.
Methods A literature search was performed to identify studies published between 1980 and 2005 comparing outcomes of patients undergoing
ileal pouch-anal anastomosis for Crohn’s disease, ulcerative colitis, and indeterminate colitis. Random-effect, meta-analytical
techniques were used and sensitivity analysis was performed.
Results Ten studies comprising 3,103 patients (Crohn’s disease=225; ulcerative colitis=2,711; indeterminate colitis=167) were included.
Patients with Crohn’s disease developed more anastomotic strictures than non-Crohn’s disease diagnoses (odds ratio, 2.12;
P=0.05) and experienced pouch failure more frequently than patients with ulcerative colitis (Crohn’s disease vs. ulcerative colitis: 32 vs. 4.8 percent, P<0.001; Crohn’s disease vs. indeterminate colitis: 38 vs. 5 percent, P<0.001). Urgency was more common in Crohn’s disease compared with non-Crohn’s disease: 19 vs. 11 percent (P=0.02). Incontinence occurred more frequently in Crohn’s disease compared with non-Crohn’s disease patients: 19 vs. 10 percent (odds ratio, 2.4; P=0.01). Twenty-four-hour stool frequency did not differ significantly between Crohn’s disease, ulcerative colitis, or indeterminate
colitis. Patients with isolated colonic Crohn’s disease were not significantly at increased risk of postoperative complications
or pouch failure (P=0.06).
Conclusions Patients with Crohn’s disease undergoing ileal pouch-anal anastomosis should be appropriately counseled toward poorer functional
outcomes and higher failure compared with non-Crohn’s disease patients. It maybe possible to preoperatively select patients
with isolated colonic Crohn’s disease who may benefit from ileal pouch-anal anastomosis with acceptable adverse outcomes.
Presented at the meeting of the European Society of Coloproctology, Lisbon, Portugal, September 13 to 16, 2006. 相似文献
11.
Therapeutic management of inflammatory bowel disease remains beyond the limits of conventional therapy in many cases. Novel
therapies used include tacrolimus, a new powerful immunosuppressive drug, employed in some case reports and a few studies
that have tried to evaluate its effectiveness in Crohn’s disease and ulcerative colitis with promising results, but its role
in the management of inflammatory bowel disease remains controversial. We performed a systematic review that analyzed a total
of 23 reported experiences in 286 patients with inflammatory bowel disease treated with tacrolimus. Although most of the published
studies are uncontrolled, short, and heterogeneous, promising results have been obtained in fistulizing disease, unresponsive
cases of both ulcerative colitis and Crohn’s disease, and even extraintestinal manifestations. The overall outcome was good
enough to consider tacrolimus as a rationale therapeutic option. However, comparative studies with standard therapeutic options
like infliximab are needed to assess the correct role that tacrolimus may play in these patients. 相似文献
12.
Infliximab: Use in inflammatory bowel disease 总被引:4,自引:0,他引:4
Opinion statement Crohn’s disease (CD) and ulcerative colitis (UC) are chronic and often debilitating inflammatory bowel diseases (IBD) without
medical cures. Despite the existence of multiple therapies, the medical treatment of these diseases often has proven insufficient
and surgery is frequently required. However, as our understanding of the pathogenesis of these disorders and other immune-mediated
inflammatory diseases (eg, rheumatoid arthritis and psoriasis) has grown, new and more specific biologic therapies have been developed that are proving
more effective than traditional agents. Infliximab is a genetically engineered monoclonal antibody that targets the proinflammatory
cytokine tumor necrosis factor-α (TNF-α) and represents the first effective biologic therapy for IBD and has largely revolutionized
treatment. Infliximab initially was developed to be used in patients with moderate to severe luminal or fistulizing CD who
are refractory to standard medical therapy. More and more practitioners now are using infliximab as first-line therapy because
of its superior efficacy. Infliximab rapidly induces remission in CD, but when given chronically, it can provide long-term
maintenance of remission. In addition, there are some data to support its use as a steroid-sparing agent and treatment for
various extraintestinal manifestations of IBD and, although used predominantly to treat CD, recent data suggest that infliximab
also may have a role in the management of UC. Overall, infliximab represents a clinically useful, cost-effective therapy that
works well, even though careful patient monitoring is required to avoid rare but significant toxicities. The hope is that
infliximab, together with other biologic agents that currently are in development, will allow us to modify the course of IBD,
avoid complications such as strictures and abscesses, and reduce the need for surgery. 相似文献
13.
Isaacs KL 《Current Treatment Options in Gastroenterology》2007,10(1):61-70
Opinion statement Esophageal damage is an uncommon manifestation of Crohn’s disease. The diagnosis should be considered in patients who have
other intestinal manifestations of Crohn’s disease and present with esophageal symptoms. Diagnosis should be based on history,
known extraesophageal Crohn’s disease, endoscopic evaluation with biopsy, and exclusion of gastroesophageal reflux disease.
Mild disease should be treated with acid suppression and a short course of steroids. 5-amino-salicylates are not likely to
be effective due to drug release characteristics. Patients who have moderate to severe disease should be treated aggressively
with acid suppression, a longer course of steroids, and consideration of immunosuppressive therapy with 6-mercaptopurine or
azathioprine. Infliximab or other anti-tumor necrosis factor therapy also can be considered in refractory patients to try
to prevent the complications of stricturing and fistula formation. In those patients who develop strictures of the esophagus,
treatment with balloon dilatation of the stricture followed by injection of a long-acting steroid such as triamcinolone will
help to alleviate symptoms. Surgery may be required for severe, refractory symptoms, but it has a high morbidity in this population. 相似文献
14.
The aim of this study was to prospectively evaluate the correlation between clinical scoring systems and C-reactive protein
(CRP) in inflammatory bowel disease. The modified Harvey-Bradshaw index was used in 40 patients (58 assessments) with Crohn’s
disease, and the Lichtiger score in 29 patients (36 assessments) with ulcerative colitis. In ulcerative colitis, CRP was elevated
in 14%, 42%, 64%, and 83%, respectively, of subjects with quiescent, mild, moderate, and severe disease. There was a linear
correlation of log(CRP) with clinical score except for proctitis. In Crohn’s disease, CRP was elevated in 54%, 70%, 75%, and
100%, respectively, of subjects with quiescent, mild, moderate, and severe disease. We conclude that the clinical score has
a good correlation with CRP in ulcerative colitis except for proctitis, whereas clinical score has a poor correlation with
CRP in Crohn’s disease, particularly in those with clinically quiescent, fibrostenotic, and ileal disease. 相似文献
15.
Abreu MT 《Current Treatment Options in Gastroenterology》2004,7(3):169-179
Opinion statement Crohn’s disease and ulcerative colitis (UC) are heterogeneous disorders, and as such, the response to therapy is likewise
heterogeneous. Therefore, stratification of patients into distinct phenotypes and potentially genotypes will lead to more
definitive answers with respect to evaluation of novel and established therapies. 相似文献
16.
Advances in medical therapy for Crohn’s disease 总被引:1,自引:0,他引:1
Therapeutic research in Crohn’s disease has been intensified in recent years. This has led to many novel approaches and insights
into the mechanism of action of ‘classic’ drugs. Antibiotics remain valuable but do not offer benefit when used in addition
to corticosteroids. Immunomodulators remain the cornerstone for maintenance therapy, although certain corticosteroid-dependent
patients can be switched to maintenance therapy with topical steroids. Azathioprine and 6-mercaptopurine remain efficient
beyond 4 years in patients with relapses and elevated C-reactive protein in spite of this therapy. Infliximab has shown efficiency
in maintenance of active and fistulizing Crohn’s disease. In addition, ‘automatic reinfusion’ was found to be superior to
‘on-demand’ treatment. Infusion reactions and loss of response, most often caused by antibodies against infliximab, can be
prevented with immunomodulators and corticosteroid infusions before dosing. Such alternative anti-tumor necrosis factor agents
as adalimumab or CDP-870 may be less immunogenic. Other biologic agents, such as the anti-integrin monoclonal antibody natalizumab,
were shown to be effective in maintaining remission and somewhat less so in induction of remission. Finally, much attention
is being paid to alteration of the luminal flora with probiotics and helminth ova. Extracorporeal apheresis and even stem
cell transplantation were found to be effective in isolated patients, but these therapies warrant further prospective and
controlled investigation. 相似文献
17.
Opinion statement The success of biological therapy is best advocated by infliximab (IFX), which has dramatically improved medical therapy for
Crohn’s disease and now has been shown to be effective in the treatment of ulcerative colitis. Other anti-tumor necrosis factor
(TNF) compounds have been tested in the treatment of Crohn’s disease and will soon appear in the therapeutic armament. However,
neutralization of TNF does not seem to be the most important mechanism of action of these therapies. Apoptosis of activated
T cells was demonstrated after IFX treatment, and this may be the key to its success. Thus, other therapies that induce apoptosis
in activated T cells, such as visilizumab, have a great chance to be of benefit. Biological therapies applied in inflammatory
bowel disease appear to be safe, although therapy-related adverse events clearly have been recognized. 相似文献
18.
Immunomodulators are a class of drugs that attenuate the underlying inflammatory processes of Crohn’s disease (CD) and ulcerative
colitis (UC), the two major inflammatory bowel diseases (IBD). These agents play a prominent role in the management of refractory
and steroid-dependent IBD. The immunomodulatory drugs in the IBD arsenal include azathioprine, 6-mercaptopurine, methotrexate,
cyclosporine, and tacrolimus. Azathioprine and 6-mercaptopurine are considered firstline immunosuppressants due to their proven
efficacy in both CD and UC and their safety profile, whereas cyclosporine occupies a niche as a surgery-sparing agent in the
acute management of severe, steroid-refractory UC. Immunomodulators also appear to have a role as adjunctive therapy when
used with infliximab or other biologic agents to reduce immunogenicity. Although data have been limited to observational studies,
azathioprine and 6-mercaptopurine may be used during pregnancy. 相似文献
19.
Melmed GY Fleshner PR Bardakcioglu O Ippoliti A Vasiliauskas EA Papadakis KA Dubinsky M Landers C Rotter JI Targan SR 《Diseases of the colon and rectum》2008,51(1):100-108
Purpose Approximately 5 to 10 percent of patients undergoing ileal pouch-anal anastomosis with a diagnosis of ulcerative colitis are
subsequently diagnosed with Crohn’s disease. Preoperative predictors for Crohn’s disease post-ileal pouch-anal anastomosis
have not been prospectively defined.
Methods A total of 238 consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis
were prospectively enrolled into a longitudinal database. Clinical factors were assessed perioperatively. Serum drawn preoperatively
was assayed for anti-Saccharomyces cerevisiae, antiouter membrane porin-C, anti-CBir1, and perinuclear antineutrophil cytoplasmic antibody using enzyme-linked immunosorbent
assay. Crohn’s disease was defined by small bowel inflammation proximal to the ileal pouch or a perianal fistula identified
at least three months after ileostomy closure. Predictors were assessed in a multivariate Cox proportional hazards model to
predict the rate of Crohn’s disease after ileostomy closure.
Results Sixteen patients (7 percent) were diagnosed with Crohn’s disease; median time to Crohn’s disease was 19 (range, 1–41) months.
Significant factors for postoperative Crohn’s disease after ileal pouch-anal anastomosis included family history of Crohn’s
disease (hazard ratio, 8.4; 95 percent confidence interval, 2.96–24.1; P < 0.0001) and anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity (hazard ratio, 3.14; 95 percent confidence interval, 1.1–9.81; P = 0.04). Crohn’s disease developed in only 8 of 198 patients (4 percent) without these predictors vs. 8 of 40 patients (20 percent) in those with at least one of these factors (P = 0.002). The cumulative risk of Crohn’s disease among patients with two risk factors (67 percent) was higher than in patients
with either risk factor (18 percent) or neither risk factor (4 percent, P < 0.001).
Conclusions Patients with ulcerative colitis and indeterminate colitis with a family history of Crohn’s disease or preoperative anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity are more likely to be diagnosed with Crohn’s disease after ileal pouch-anal anastomosis.
Poster presentation of distinction at Digestive Disease Week, Washington, D.C., May 19 to 24, 2007, and Read at the meeting
of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 7, 2007.
Financial disclosures: Prometheus Laboratories Speakers’ Bureau (Eric A. Vasiliauskas, Konstantinos A. Papadakis, Marla Dubinsky,
Andrew Ippoliti), shareholder (Carol Landers, Stephan R. Targan), and cofounder (Stephan R. Targan). 相似文献
20.
Opinion statement
相似文献
– | The role of nutritional intervention in inflammatory bowel disease (IBD) is twofold: first, as primary therapy for patients with acute Crohn’s disease; second, as an invaluable adjunctive therapy for the correction and maintenance of nutritional status for both patients with Crohn’s disease and those with ulcerative colitis. Careful nutritional monitoring and appropriate nutritional intervention throughout all stages of disease should be an integral part of the multidisciplinary management approach to IBD. |
– | In terms of primary therapy, polymeric and elemental enteral diets are an effective therapy for patients with acute Crohn’s disease, offering an unrivaled safety profile and significant nutritional benefits. Enteral diets should be considered as primary therapy in children with Crohn’s disease, especially in those with poor nutritional status or growth impairment, and in patients with severe drug-induced side effects. Total parenteral nutrition (TPN) does not have a primary therapeutic role in patients with IBD. |