On October 11th, I had the opportunity to discuss my blog at our national meeting (Why I blog | gutsandgrowth). My copresenter Eric Benchimol discussed social media more broadly. Here is a link to his slides (with permission):
Author Archives: gutsandgrowth
Screening for NAFLD
As noted in previous blogs (see below), there is not a consensus with regard to screening for NAFLD in overweight and obese patients. While some have argued for aggressive screening leading to an expensive tiered evaluation, other experts have been reluctant to endorse this approach, in part due to the magnitude of the problem and due to the perceived lack of therapeutic options. Weighing in on this controversy is a new study (Aliment Pharm Ther 2013; DOI: 10.1111/apt.12518, link -from Jeff Schwimmer’s twitter feed: http://t.co/q1CUKBJtVo).
In the study’s introduction, the prevalence of NAFLD, estimated to be 9.6% of all children aged 2-19 years, along with society guidelines are reviewed.
The authors examined information from the clinical evaluation of 347 children (>10 years) [overweight (7%)/obese (93%)] who were referred by their primary care physician due to either an elevated ALT or suspected NAFLD. Referral was at the discretion of the primary care attending and not based on a specific ALT value. Median age was 13.5 years and 64% were boys.
1st tier: Subsequently, all patients underwent hepatic panel, GGT, CBC/diff, and coagulation studies. 2nd tier: If abnormal, the next set of labs may have included any or all of the following: studies for hepatitis infection (HAV, HBV, HCV), HIV, alpha-1-antitrypsin, ANA, anti-smooth muscle antibody, anti-liver kidney microsomal antibody, quantitative IgG, ceruloplasmin, 24-h urinary copper, tissue transglutaminase antibody, serum IgA, serum amino acids, urine organic acids, serum acylcarnitine, creatine kinase, ESR, CRP, and thyroid studies. (The authors did not evaluate iron status.) 3rd tier: Then, if evidence of chronic liver disease, patients were offered a liver biopsy under general anesthesia.
Results:
- 21% did not have significant liver disease (after 1st tier). Also, 3 liver biopsies were normal.
- 94% of 273 with evidence of chronic liver disease underwent liver biopsy; no significant complications were noted, though a small percentage had some discomfort.
- Ultimately, 55% were determined to have NAFLD (75% of those who underwent liver biopsy.
- The authors report that 61 patients who had a liver biopsy had another liver disease, including autoimmune hepatitis in 11, celiac disease in 4, sclerosing cholangitis in 1, and drug-induced in 6.
- Advanced fibrosis was noted overall in 11% (38 of 347) and in 17% of those with NAFLD. Those with advanced fibrosis were more likely to have higher aminotransferases (eg. ALT 120 U/L compared with 82 U/L), higher GGT, and higher ceruloplasmin; however, there was significant overlap.
- Approximately half of NAFLD patients had steatohepatitis.
Take-home message: while this article does not resolve the issue of whether screening overweight/obese children is the best strategy, it does provide useful information in those with elevated liver tests. Careful investigation for treatable causes (and possibly nontreatable) of liver disease is worthwhile in those with sustained abnormalities in transaminases. At a minimum, tests for autoimmune hepatitis, celiac disease, viral hepatitis, and Wilson’s disease should be at the top of the list.
Related blog entries:
Breakthrough for Fatty Liver Disease?
Could bile acids play a role in reducing metabolic syndrome and in particular fatty liver disease? This question is now being studied (Gastroenterology 2013; 145: 574-82).
This recent study examined whether obeticholic acid (OCA) which is a semisynthetic derivative of the human bile acid chenodeoxycholic acid could aid with insulin resistance and ultimately nonalcoholic fatty liver disease (NAFLD). OCA is an agonist of the farnesoid X receptor which is a nuclear hormone receptor that regulates glucose and lipid metabolism.
The authors performed a phase 2, double-blind, placebo-controlled study to assess the effects of OCA on insulin sensitivity in patients with NAFLD and type 2 diabetes mellitus. Patients received either placebo (n=23), 25 mg OCA (n=20), or 50 mg OCA (n=21) once daily for 6 weeks. Using an insulin clamp, insulin sensitivity was measured before and after the study period. Numerous blood tests were obtained as well.
Results:
- Insulin sensitivity improved 28% in the 25mg OCA group and 20.1% in the 50 mg OCA group whereas it decreased 5.5% in the placebo group.
- The OCA groups also had significant reductions in gamma-glutamyltransferase, alanine aminotransferase, and dose-related weight loss.
- Markers of liver fibrosis decreased in the 25 mg OCA group.
- Side effects of OCA were minimal. Constipation was reported in the 50 mg OCA group.
Take-home message: OCA may help patients with NAFLD and a bigger, longer study is in the works (FLINT study: 25 mg OCA for 72 weeks compared with placebo, http://www.clinicaltrials.gov; NCT01265498)
Related blog posts:
- NAFLD Guidelines 2012 | gutsandgrowth
- Pediatric NAFLD histology score | gutsandgrowth
- Could Cysteamine help NAFLD? | gutsandgrowth
- pediatric nafld position paper | gutsandgrowth
- Can NALFD be improved with bile acid … – gutsandgrowth – Blog
- A liver disease tsunami | gutsandgrowth
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Why I blog
I was asked to participate in a “Meet the Professor Breakfast Session” at the NASPGHAN Annual Meeting. This year’s meeting is taking place at the Chicago Hilton Downtown, October 9-11th. The proposed title of my session:
“Twitter/Facebook/Blog- Use of Technology in your practice”
Co-presenter: Eric Benchimol; time 7am (central) tomorrow morning (October 11)
My focus will be to discuss this blog and how it relates to my practice. I started this blog shortly after the NASPGHAN meeting in 2011. There were two main factors that contributed to starting this blog.
1. The death of the palm pilot and other PDAs. After my fellowship, in 1997 I joined Mike Hart in Atlanta at Egleston Children’s Hospital. He had started using a palm pilot and I began using one as well. I stored a lot of useful information on drugs and personal contacts. By each local physician, in addition to their name, I kept the names of referred patients and their diagnoses. I also decided that instead of tearing journals I would make entries in my Palm device and keep annotated references of journals that I was reading. When the support services disappeared for my Palm device, I transferred a lot of information to Notespark but was not as pleased with this site as I had been with my Palm.
2. NASPGHAN meeting. While at the NASPGHAN meeting, I listened to a talk by Bryan Vartabedian (33 Charts — medicine. health. (social) media). Prior to that meeting, I had not considered starting a blog. He made several points that I considered important.
- Physicians need to provide a voice and balance in social media. In many areas of medicine, like immunizations, the voices of extremists dominant the conversation. “The solution to pollution is dilution.” When physicians add their reasoned opinions to topics related to public health, this will steer the conversation towards sanity.
- Taking part in social media allows a physician to modify their digital footprint. Without our participation, what is placed on the internet is beyond our control (Physician Online Reputation Management – 2 Realities – 33 Charts).
His blog on social media and medicine has been present for many years and elaborates on these points and many others.
So I decided to start a blog. This might sound difficult but it wasn’t. I didn’t even need to ask my teenage sons for hardly any help. Though, in retrospect, it may have been a good idea. I found that wordpress.com provides tools for individuals to create their own blogs at no cost (alternative sites are noted in my slides -see link below). Though, they definitely encourage an upgrade ($18 per year). Basically, I registered a name, picked a design type for the blog, and made a few choices about the formatting.
If you have time, you can look at some amazing blogs: photographers post pictures from all corners of the earth, professional chefs & domestic chefs provide recipes for anything you could think of eating, Nate Silver can tell you who is going to win the next presidential race, KevinMD has thoughtful posts from a huge number of health professionals, our hospital (like many others) has a blog, improvecarenow has a blog, there are blogs explaining the NEJM articles, my sister has a blog about what turning 50 means, and so many others.
What were my goals/Why I blog?
- To create a site where I could archive the references of journal articles and have them accessible for easy searching.
- To develop a relatively non-controversial digital footprint. Truth be told, I would love to create a joke blog. However, I think that anything you put out on the internet is available for public consumption and I am certain that some of my jokes would not be well-received in some circles.
- To add my voice to topics like immunization policy, judicious use of antibiotics, and healthy nutrition choices.
- To share some of my readings with my colleagues and mid-level providers. I hoped that some of the information might help with more uniform adoption of best practices. For example, with H pylori, we have an international expert in our group (Benjamin Gold who is speaking at this conference). Yet, the information that clarithromycin should not be a 1st line drug had not been brought up in any of our meetings.
- To promote some aspects of our groups’ accomplishments. When one of our physicians publishes an article, I definitely want to review that for my blog.
- To remember journal articles with more clarity.
While many physicians might see the opportunity for patient education, I decided to target the blog to a medical professional audience. Our office website (Children’s Center for Digestive Healthcare, LLC (GI care 4 kids) already has a great deal of patient-related information and links to numerous other useful sites.
When I first started the blog, I only notified a few people outside of our group. This included my mentors in Cincinnati (including Mitchell Cohen, William Balistreri, and Jim Heubi) as well as my former boss Mike Hart. All of these individuals, along with my other mentors in training (Colin Rudolph, Jorge Bezerra, Mike Farrell, and Jon Bucuvalas), could probably provide a great deal more insight.
After writing a few blogs, I decided I would send an email to authors of papers that I commented on. This would allow them to provide additional insight as well if they chose. After about a year of blogging, Mike Hart asked if I was OK with him sending an email out to the pediatric GI bulletin board listserv because he thought more people might enjoy the blog’s contents. Also, now I usually will post a link on twitter so that individuals who follow me can access the blog as well.
Many physicians have avoided social media due to either time constraints or concerns of potential risk about putting out medical information. I do put in time and try to be careful about what I write. And, unlike medical journals, I do not have any editors.
At the same time, I have a lot of advantages.
- I can provide links to media. Some of these links are just for fun. For example, in previous posts: “dont go ninjin nobody that dont need ninjin” Kung Fu Hillbilly – Training Video – YouTube or “Everybody Poops” – a bad lip reading of the Black Eyed Peas …. In addition, it is not difficult to place graphs or pictures.
- I can provide links to newspaper articles and original publications.
- I have the opportunity to provide more timely information.
- The information on my blog is much easier to search.
- Many other physicians forward me articles that they think would be of interest.
- I can link previous related posts. This is a lot easier than tracking down other types of references.
- I can use twitter to leverage a great deal of information. For example, Kipp Ellsworth has a twitter feed, @PedNutritionGuy, which cites a large number of relevant nutritional studies. Jeff Schwimmer has a twitter feed, @TheLiverPost, which highlights recent hepatology advances.
- The blog site has a lot of tools, like widgets, which can help present useful information
Since my blog is mainly for health professionals, I have on occasion written patient-related information for our hospital blog: When a Child Swallows a Button Battery – Dedicated to All Better. I’ve been told that this posting has had more than a thousand views.
Full presentation (powerpoint): WhyIBlogSlides
Related post:
What is the role for preventing variceal bleeding in Biliary Atresia?
During medical school, I read a book called “The House of God” (The House of God – Wikipedia, the free encyclopedia. One of this cynical book’s premises is that doing more diagnostic tests and treatments to help patients actually harms them.
A recent study of children with biliary atresia reminded me of this premise (Gastroenterol 2013; 145: 801-7, eidtorial 719-22). In this retrospective study, there were 66 children with endoscopic evidence of portal hypertension who underwent endoscopic therapy for either primary (n=36, mean age 22 months) or secondary (n=30, mean age 24 months) treatment of esophageal varices biliary atresia (2001-2011). These children were at high risk for bleeding; they had a mean bilirubin of >10 mg/dL and 20% had ascites.
Results:
Primary prophylaxis group: mean of 4.2 sessions were needed to eradicate varices. Varices reappeared in 37%; there was no breakthrough bleeding. 97% survived for 3 years. All of these patients had varices grade 2 or higher and 94% had red wale markings.
Secondary prophylaxis group (after previous bleeding): mean of 4.6 sessions to eradicate varices. Varices reappeared in 45% and 10% had breakthrough bleeding. 84% survived for 3 years.
Treatment:
- For bleeding group, sclerotherapy was used in 73%, banding in 17%, and both in 10%.
- For prophylaxis group, sclerotherapy was used in 44%, banding in 41%, and both in 14%.
- By the end of the study, sclerotherapy was mainly used in patients weighing less than 8 kg.
- Each endoscopy session had the same endoscopist, used octreotide (2 mcg/kg/hr) an 1 hour before and then for 2-3 days afterwards.
- With bleeding patients, these sessions occurred after the patient was stabilized, with a mean of 10 days afterwards.
- Patients had an average of four 3-day hospitalizations.
- Within an average of 14 months, more than half of the primary prophylaxis group had undergone transplantation
The authors interpret their data as follows: “primary or secondary prophylaxis of bleeding is well tolerated and greatly reduces the risks of variceal bleeding in children with biliary atresia and high-risk gastroesophageal varices. The results support the active detection of these signs by endoscopic procedures.”
In contrast, the editorial is much less supportive of primary prophylaxis. “We need to weigh the risks and benefits of multiple procedures in a nonbleeding child who may not bleed for years, when varices have a high chance of recurring and transplant is sometimes imminent. Because mortality from gastrointestinal bleeding in children is quite low (zero in this small study), we may need to consider a ‘wait and see’ approach.”
Bottomline: A failed Kasai is an indication for transplantation which is a much more definitive treatment for portal hypertension.
Previous related blog posts:
Nexium versus Fluticasone for EoE
As noted in previous blog posts (EoE: Drugs, Diets, Dilatation and PPI-REE | gutsandgrowth, EoE –Journal Club (Part 1) | gutsandgrowth, and EoE –Journal Club (Part 2) | gutsandgrowth), proton pump inhibitors are recommended as 1st line therapy in suspected eosinophilic esophagitis (EoE) for several reasons. Besides the potential for gastroesophageal reflux to cause esophageal eosinophilia, there has been recognition of PPI-responsive eosinophilic esophagitis (PPI-REE). In adults, the response to proton pump inhibitors, both clinically and histologically, is likely higher than in children; nevertheless, in children it is anticipated that 20-40% of patients with suspected EoE will have a histological remission with PPI therapy.
A recent study in adults suggests that PPIs may in fact outperform topical steroids (Am J Gastroenterol 2013; 108: 366-72). Thanks to Ben Gold and Seth Marcus for identifying this reference. This study enrolled 42 patients: 90% male, 81% white, mean age 38 years. It was a prospective single-blinded, randomized controlled trial with newly suspected EoE; half of the patients received esomeprazole 40 mg daily and half fluticasone swallowed aerosol 440 mcg twice a day. After 8 weeks, all patients had repeat endoscopy; a total of eight biopsies were obtained –four at two locations: 15 cm above LES and 3 cm above LES. In addition, at the start of the study, patients also underwent 24-h pH/impedance monitoring. 4 of the 21 patients in each group had abnormal degrees of gastroesophageal reflux/gastroesophageal reflux disease (GERD).
Study characteristics note that 62% of patients had coexisting atopic disorders.
Results:
- There was no significant difference in esophageal eosinophilia response with 19% of the fluticasone and 33% of the esomeprazole achieving an eosinophil count < 5/hpf (P=0.484)
- In patients with coexisting GERD, all 4 esomeprazole patients achieved histologic remission compared with none of the fluticasone-treated patients.
- When the GERD patients were excluded, the histological remission was quite similar: 24% with fluticasone and 18% for esomeprazole.
Overall, this study population had a lower rate of response to topical steroids than in multiple previous studies. More typically, response rates of ~50% have been reported; however, studies have shown lower responses in some adult studies. Variability in response could be related to multiple factors included dosage, duration, delivery, and definition of response. In addition, population characteristics included disease duration and frequency of underlying atopic disease and GERD play a role.
Take-home points: Although this is a small study, it reinforces the fact that PPIs induce a histological response and clinical response in some patients suspected of having EoE regardless of whether GERD is present. PPIs are considered 1st line therapy. Topical fluticasone had a lower response rate in this study. However, in clinical pediatric practice, topical steroids are effective in about 50% of patients.
Additional related blog entries:
- CHOOSING TOPICAL THERAPY FOR EOE | GUTSANDGROWTH
- GUIDELINES FOR EOSINOPHILIC ESOPHAGITIS | GUTSANDGROWTH
- EOSINOPHILIC ESOPHAGITIS –SIX FOOD GROUP DIET | GUTSANDGROWTH
- LOOK OF IMPROVEMENT ON AN EOE DIET | GUTSANDGROWTH
- STRING TEST | GUTSANDGROWTH
- LOOKING BETTER OR FEELING BETTER IN EOE? | GUTSANDGROWTH
- THE UNDISCOVERED COUNTRY | GUTSANDGROWTH
Crohn’s Research: Going to Pot
A recent pilot study using Cannabis for Crohn’s disease is certain to attract a lot of attention (Clin Gastroenterol Hepatol 2013; 11: 1276-80). The side effects are definitely less frightening than many of the accepted treatments.
Background: Cannabis has a long record of medicinal uses; it contains more than 60 different compounds, though Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are thought to be the most active. Cannabis has known antiinflammatory properties and has been shown to reduce colitis in a mouse model.
Study design/characteristics: 21 of 51 screened patients participated; these patients had active Crohn’s disease despite thiopurines in 20 or 21 and anti-tumor necrosis factor (TNF) therapy in 18. These 21 patients were enrolled in a double-blind, placebo-controlled study. The average age in the cannabis group was 46 years compared with 37 in the placebo group. Both groups received cigarettes twice daily; the cannabis cigarettes had 115 mg of THC whereas the placebo group had cannabis flowers in which the THC had been extracted. Though this was a double-blind study and efforts were made to mask the psychotropic effects by recruiting patients naive to cannabis, nevertheless, by the end of the study most of the patients knew whether they were in the active group or the placebo group.
Results:
- Cannabis group had a 45% remission rate (5 of 11) with a CDAI of ≤150; the placebo group had a 10% remission rate. This did not achieve statistical significance.
- The response rate (CDAI drop of >100) was noted in 90% (10 of 11) of cannabis group compared with 40% in the placebo group.
- The mean CDAI reduction was 177 in the study group compared with 66 in the placebo group (P= .005).
- There were no significant laboratory changes (eg. Hgb, CRP, LFTs, kidney function).
- No significant side effects were noted. The study group reported less pain, improved appetite, and better satisfaction with their treatment.
In their discussion, the authors note that this is a small study. They chose the smoking route with THC-rich cannabis to achieve higher blood levels, but note that oral dosing may be effective. The 8-week duration of the study and lack of more objective markers of response precludes firm conclusions.
Take-home message: Cannabis should be studied further for its potential role in controlling inflammation. This study’s timing will increase the broader interest in medical marijuana applications.
Related links:
Probiotics, Atopy, and Asthma
Moving from theory to practice with probiotics has been problematic in many areas. That is, theoretically probiotics by altering the microbiome should have numerous beneficial effects; however, demonstrating these positive effects in practice has been difficult for many conditions. A recent study (thanks to Mike Hart for this reference) highlights this issue with regard to asthma: Pediatrics 2013; 132: e666-76. Full article:
http://pediatrics.aappublications.org/content/132/3/e666.full.html
Background: Due to the immune modulating effects of probiotics and mindful of the hygiene hypothesis regarding the rise of atopic diseases, some have proposed the use of probiotics to reduce the risk of atopy and asthma in children.
Methods: In this study, the authors performed a meta-analysis of numerous randomized studies. Out of a total of 1081 articles, 25 studies met predefined criteria, with a total of 4031 participants (see Table 1 in publication). Numerous probiotics were administered. The most common probiotic in these trials, Lactobacillus GG, was used in 8 of the studies.
Results:
- For serum immunoglobulin E (IgE) levels, 9 of the trials (n=1103) provided data. Probiotics were associated with a -7.59 U/mL reduction in total IgE (P= .044). The effect of probiotics was more pronounced with longer, follow-up periods.
- Probiotics, in comparison to placebo, were associated with a reduced risk of atopic sensitization based on positive skin prick and/or elevated specific IgE to common allergens. This was true whether the probiotic was administered prenatally (relative risk 0.88, P=.035) or postnatally (relative risk 0.86, P=.027)
- Probiotics did not reduce the risk of asthma/wheeze (relative risk 0.96 [95% CI 0.85-1.07]
Study limitations: heterogeneity of clinical trials in meta-analysis, various probiotic strains, variable duration and timing of probiotic use.
Related blog posts:
Should Physicians Dispense Drug Coupons?
This is a good question. Before you answer, consider some of the following information from a recent commentary (NEJM 2013; 369: 1188-89):
- “Commercial drug-insurance…have tiered pharmaceutical formularies..requiring small patient copayments…for inexpensive generic drugs and higher copayments…for brand-name drugs. Manufacturers use coupons…so that…the out-of-pocket costs are the same as those for generic drugs.”
- “Coupons were used for approximately 100 million dispensed prescriptions in 2010 –about 11% of prescriptions for brand-name drugs.”
- The authors performed analysis ‘by manually abstracting information on each coupon advertised in March 2013 at http://www.internetdrugcoupons.com.” They found that with 62% of coupons there were lower-cost therapeutic alternatives available. 58% had generic alternatives and 8% had less-expensive brand-name therapeutic equivalents (some drugs had both generic alternatives and less-expensive brand competitors).
The arguments against coupons:
- “On a population level, drug coupons undermine the tiered-formulary system that commercial insurers have implemented to limit prescription-drug spending.” Insurers must still pay the higher cost of the brand-name drug. This leads to higher insurance coverage rates for all patients.
- Some have argued that these coupons should be disallowed as illegal kickbacks by subverting the cost-sharing arrangements in patients’ insurance contracts.
- The costs for these medications for the patient usually are more in the long run as these coupon offers are often limited to 6-12 months.
Bottomline: when there are lower cost therapeutic alternatives, drug coupon programs increase long-term costs and undermine efforts for patients to have ‘skin in the game.’
Related blog:
Thiopurines = Low Efficacy for Crohn’s
The enthusiasm for thiopurine therapy for Crohn’s disease (CD) had already dropped a lot before two pivotal articles were recently published that confirmed the modest efficacy:
- Cosnes J, et al. Gastroenterol 2013; 145: 758-65
- Panes J, et al. Gastroenterol 2013; 145: 766-74
- Gastroenterol 2013; 145: 714-16 (editorial)
The Cosnes study (from the GETAID group) reports an open-label randomized trial in 147 adult patients with newly diagnosed CD (from 2005–>2010) and risk factors for disabling disease who were recruited from 24 French centers. Risk factors for disabling disease:
- Age <40 years
- Active perianal lesions
- Corticosteroid use within 3 months of diagnosis
The characteristics and Paris classification are detailed in the paper’s Table 1. Patients were divided into early azathioprine or “conventional” treatment. Patient’s were followed for 3 years. Azathioprine was dosed at 2.5 mg/kg/day. The primary endpoint was the proportion of trimesters spent in corticosteroid-free and anti-tumor necrosis factor (TNF)-free remission.
Results:
- 67% of azathioprine group achieved the primary endpoint compared with 56% in the conventional group. The difference in achieving the primary endpoint was not statistically significant between the two groups. Also, 41 (61%) of the conventional group were placed on azathioprine (mean time 11 months after enrollment).
- The azathioprine group patients were more likely to not have perianal surgery (96%) compared with the conventional group patients (82%).
- Adverse events included pancreatitis in 7 (10%) of azathioprine group compared with 1 (1%) of conventional group. Elevated liver function tests were noted in 3 (4%) compared with 1 (1%) respectively. No cases of neutropenia were noted in early azathioprine group.
The latter finding is interesting especially as the authors did not check thiopurine methyltransferase (TPMT) assays in a systematic manner.
Panes et al (for the AZTEC study group) performed a prospective double-blind trial of adult patients with a recent CD diagnosis (<8 weeks). This study enrolled 131 patients from 31 centers in Spain. 68 received azathioprine (2.5 mg/kg/day) and 63 received placebo.
Results:
- After 76 weeks of treatment, 30 (44.1%) azathioprine patients and 23 (36.5%) placebo-treated patients were in sustained corticosteroid-free remission (P= .48).
- Relapse rates were lower in azathioprine group compared with placebo: 11.8% vs 30.2%.
- Serious adverse effects were more frequent in the azathioprine group compared with placebo: 20.6% vs. 11.1% (P= .16). In the azathioprine group, 7 (10%) developed pancreatitis, 16 (24%) developed leukopenia, 9 (13%) developed anemia, and 9 (13%) developed abnormal liver function tests. Infections were more common in the placebo-treated group (24%) compared with 12% in the azathioprine group
The accompanying editorial should be mandatory reading for all health care providers who help manage inflammatory bowel disease (IBD) patients. The editorial traces how thiopurines (azathioprine and 6-mercaptopurine) became an accepted cornerstone of IBD treatment. In adults, after initial disappointing results from Summers et al (Gastroenterol 1979; 77: 847-69), efficacy was demonstrated in a seminal study by Present et al (NEJM 1980; 302: 981-87). However, the authors note that a recent Cochrane review reported that “thiopurines are not effective for induction of remission, but are effective for maintenance of remission.”
The editorial notes that a high degree of efficacy was demonstrated from a small but influential pediatric study of 55 patients. After a high remission rate (89%) for all patients, this study showed that among those in remission, “1 patient (4%) in the 6MP group had a relapse within 180 days of achieving remission, compared with 7 patients (28%) in the placebo group.”
The editorial draws the following conclusions from the current studies:
- “The remaining indications for primary therapy with thiopurines are maintenance of steroid-induced remission/steroid sparing in patients with CD that is not newly diagnosed, and prevention of postoperative recurrence.”
- “The strongest indication for thiopurines may be as part of combination therapy.”
- “If TNF antagonists had a similar low cost as generic thiopurines, there would likely be little debate regarding an evolution toward treatment of CD with TNF antagonists, either as monotherapy or ideally as combination therapy. Currently, the annual costs of TNF antagonists is 10-20 times that of thiopurines.”
- Because of the difference in cost.., “the use of thiopurines in CD is likely to persist, despite the shrinking number of indications, the modest effect size, and the suboptimal safety profile.”
Related blog posts:
- Mixed-review for Thiopurines | gutsandgrowth
- Only one chance to make first impression | gutsandgrowth
- Thiopurine Metabolite Testing -NASPGHAN … – gutsandgrowth
- Understanding IBD Therapy Risks -A Good Link | gutsandgrowth
- Thiopurines associated with reduced risk of colon … – gutsandgrowth
- Assessing and discussing risk of lymphoma in IBD | gutsandgrowth
- Drug levels for inflammatory bowel disease | gutsandgrowth
- Natural laws not patentable: the case with … – gutsandgrowth
- More on IBD medicine risks | gutsandgrowth
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