Two recent articles add some useful information regarding enteral therapy for Crohn’s disease (Inflamm Bowel Dis 2012; 18: 246-53 & JPGN 2012; 54: 298-305).
The first article enrolled 34 children with newly-diagnosed Crohn’s disease. Patients were divided into elemental and polymeric formula groups and followed in a prospective, double-blind randomized controlled trial for two years. Measures of improvement included the PCDAI as well as fecal calprotectin and fatty acids. Both groups of patients responded clinically. 93% (14/15) of the elemental formula group achieved remission based on PCDAI scores (<11) and 79% (15/19) of the polymeric formula group. The initial treatment was use of formula (along with only clears) either by NG or oral for 6 weeks. All patients had NG placed at time of endoscopy and if sufficient oral intake was demonstrated (for 2 days), NG was removed. All subjects had small bowel and colonic disease. Although calprotectin levels decreased, they remained very elevated. In the EF group, the median calprotectin dropped from 2023 μ/g to 1113 μ/g, though only one patient had a level below 400; similarly in the PF group the calprotectin dropped from 1929 μ/g to 1134 μ/g, and only two patients had a level below 400. Some to the reasons why changes in diet may be useful have been alluded to in a previous post: Eat your veggies…if you don’t want to get sick.
The second reference is a clinical guideline on the use of exclusive enteral nutrition EEN). The introduction notes that 65% of European pediatric gastroenterologists use EEN compared to 4% for North American pediatric gastroenterologists. In pediatric trials, EEN and corticosteroids were considered ‘equally effective’ in a pediatric meta-analysis which included five randomized controlled trials (n=147). However, a Cochrane review favored corticosteroid treatment over EEN in a meta-analysis that included adult and pediatric patients (n=192 EEN, n=160 corticosteroids). According to the authors, small studies have demonstrated other potential advantages of EEN including higher rates of mucosal healing and better linear growth. With regard to mucosal healing, the initial cited study casts with ongoing elevated calprotectin indicates that this does not occur in the majority of children with EEN therapy. Other caveats:
- Disease location: some evidence favors small bowel disease rather than colonic disease
- Formula composition: does not seem to matter whether elemental or polymeric
- Duration of therapy: majority treat for 6-8 weeks of EEN. The authors recommend at least 8 weeks
- Time for response: Inflammatory markers improve in a little as a week, remission typically 2-4 weeks
- Concomitant medications: many places initiate immunomodulator treatment; others cycle EEN
- Start with goal 120% of ‘maintenance’ nutrient needs. On 1st day, authors recommend starting at 1/2 goal volume and gradually increase over 1-2 days
- Partial enteral nutrition (PEN) (eg. overnight feedings & normal daytime diet) has been helpful in improving growth and may improve remission rates.
The use of more top-down therapy may affect all of the above considerations (Only one chance to make first impression).
- -Cochrane Database Syst Rev 2007; CD000542. Enteral nutritional therapy vs corticosteroids to induce remission in Crohn’s disease.
- -Gastroenterology 2011; 141: 742. AGA guidelines on use of enteral nutrition in wide variety of conditions.
- -Gastroenterology 2008; 135 : 1005. omega-3 fatty acids ineffective in Crohn’s dz for maintaining remission.
- -Pediatr Res 2007; 61: 356-60. Enteral nutrition effect on protein turnover in adolescents with Crohn’s disease.
- -J Pediatr 2000; 136: 285-91. Nutritional Rx w polymeric diet is effective w/in 8 weeks in 32/37.
- -Scand J Gastro 2001; 36: 383-8. Elemental & polymeric diets successful in maintaining remission in ~43% of adults with complete steroid withdrawal
- -JPEN 1992; 16: 499. improved wt,ht, decreased prednisone, decreased CDAI
- -JPGN 2000; 31 (supp 2) A291. Polymeric vs elemental diet.
- -JPGN 2002; 35: 339-40. Lactase deficiency – same prevalence in IBD as in RAP.
- -JPGN 2000; 31: 3 & 8. EN about as effective as steroids for primary Rx.