Yesterday’s post on “Eternal Nutrition” had a link to podcasts on enteral nutrition as therapy for Crohn’s disease. I listened to the podcasts and they were helpful (Enteral Therapy as Primary Therapy for Crohn’s Disease Podcast). A few points that were made included the following:
- Try to have the right person teach/place the nasogastric feeding tube. If the first experience is bad, this may make further attempts quite difficult. At CHOP, their facility has an education center and they schedule 3-hour learning session for enteral feeds. Teaching the teen to place the NG tube is preferred.
- Many pediatric gastroenterologists in U.S. are not informing their patients that enteral feedings are a treatment option.
- In most parts of the world, induction with enteral nutrition involves virtually 100% of diet as enteral nutrition for ~8-12 weeks. CHOP modification involves 80-90% of calories delivered enterally, typically over an overnight drip. If someone is not responding to enteral feeds, CHOP may increase calories delivered enterally.
- For maintenance with CHOP modification, gradually reduction from 7 days per week to 5 days per week is attempted. At CHOP, they prefer hydrolysate for enteral tube feedings and think more rapid gastric emptying could be helpful. However, the podcast state that specific formulas have not been shown to be superior in trials to date. At CHOP, if formula is taken orally, then an intact protein formula is selected.
- If someone uses enteral formula for maintenance, then consideration of a gastrostomy tube (after 3 months) is reasonable. They have not had local issues at sites due to Crohn’s disease.
- Resources include the Oley.org website and the Crohn’s Survival Guide.
- Enteral therapy seems to work in small bowel as well as colonic disease, despite early reports suggesting less efficacy with colonic disease.
A recent phase II study (N Yoshimura et al. Gastroenterol 2015; 149: 1775-83) indicates that an oral antagonist of α4 integrin may be quite useful for ulcerative colitis.
This double-blind, placebo-controlled trial with 102 patients found the following:
- A clinical response rate at 8 weeks of 62.7% in the treatment group and 25.5% for placebo)
- Rates of remission were 23.5% in the treatment group compared with 3.9% in the placebo group.
- Mucosal healing were 58.8%% in the treatment group compared with 29.4% in the placebo group.
- No serious adverse events were noted.
In the commentary by BG Levesque and S Ghosh (pg 1669-72), it is noted that subsequent oral integrins will be compared to vedolizumab and similar safety concerns exist; that is making sure that there are no cases of progressive multifocal leukoencephalopathy (PML) which has been associated with natalizumab therapy. For vedolizumab, the RAMP safety monitoring program has NOT identified PML in 2884 IBD patients.
The commentary (in blue) discusses several integrins as potential therapeutic targets and outlines future therapies.
- A) Induction: corticosteroids, 5- aminosalicylates, cyclosporin, and tacrolimus
- B) Maintenance: thiopurines, methotrexate, 5-aminosalicylates, and tacrolimus.
Targeted therapies (those in development phase in italics)
- A) Monoclonal antibodies (induction and maintenance): tumor necrosis factor inhibitors, vedolizumab, other integrin/adhesion molecule inhibitors, interleukin-12/23 inhibitors, and interleukin-6 inhibitors.
- B) Oral synthetic (induction and maintenance or stop and start): Jakinibs, integrin blockers, sphingosine-1-phosphate (s1P) regulators, and SMAD7 antisense oligonucleotide.
“The results of AJM300 demonstrate feasibility of such an approach, and we anticipate a proliferation of such approaches given the robust evidence supporting integrins as a target, especially if the drug can be targeted or delivered in a gut-specific manner.”
My take: There are a number of therapies being developed that are likely to transform the treatment of inflammatory bowel disease; future treatments will be more precise, more effective and have many more options.
Related blog posts:
- Mongerson -Phase II Data Available in NEJM | gutsandgrowth
- An Oral Oligonucleotide in the Crohn’s Treatment Pipeline …
- Early Look At Entyvio (Vedolizumab) in Pediatrics | gutsandgrowth
- Enthusiasm for Vedolizumab | gutsandgrowth
- Toronto Consensus: …Ulcerative Colitis | gutsandgrowth
- Lack of Meaningful Improvement in Crohn’s Patients with …