RESUMEN
Enteral nutrition has long been a therapeutic alternative often used in adult Crohn's disease patients to obtain remission or clinical response, especially in those not responding to conventional therapy such as corticosteroids. However, the increasing use of immunosuppressors (6-mercaptopurine and azathioprine, methotrexate, etc.), and the advent of biotherapies (especially anti-tumor necrosis factor-alpha (TNF-alpha) antibodies), decreased its use in adult Crohn's disease. Nevertheless, enteral nutrition remains of interest in patients presenting concomitant malnutrition (in particular in nonobstructed patients needing surgery), or in those intolerant or who failed to other therapeutics. In addition, recent studies provide data indicating its potential interest in maintenance therapy in selected patients groups. Finally, future research (in particular in the field of immuno- or pharmaconutrition) could lead to enteral formula's improvement, with better tolerance and acceptability, as well as increased efficacy.
Asunto(s)
Enfermedad de Crohn/terapia , Nutrición Enteral/métodos , Adulto , Enfermedad de Crohn/complicaciones , Glutamina/administración & dosificación , Humanos , Lípidos/administración & dosificación , Factor de Crecimiento Transformador beta2/administración & dosificaciónRESUMEN
A total of 15-19% of ulcerative colitis patients have a severe attack at some time during their illness. As a consequence of its high associated mortality and morbidity rates, a close collaboration between gastroenterologists and surgeons in their management is mandatory, in order to define, as best as possible, the timing of surgery (i.e., colectomy) when patients fail to respond to medical treatment or worsen despite optimal medical treatment. The first step in medical treatment consists of using intravenous corticosteroids as they have been demonstrated to reduce drastically the mortality rates. However, at 1 year approximately 25% of patients become corticosteroid dependent and 30% require colectomy, which can consistently affect their quality of life. Therefore, intravenous ciclosporin has been proposed as a rescue therapy, with a further improvement of short-term efficacy and reduction of surgery requirement. Nevertheless, its use is associated with a risk of toxicity and intravenous ciclosporin is not easy to use in non-specialised centres. In addition, long-term studies suggest that colectomy is often only delayed and relapse frequent. Consequently, some authors evaluate the potential use of infliximab. Available data are encouraging, reporting a significant short-term reduction in colectomy rate. Nevertheless, additional trials are required to better define the more effective and safe treatment option(s), for both the short- and long-term, in this patient setting; a question addressed in ongoing trials.
Asunto(s)
Colitis Ulcerosa/tratamiento farmacológico , Corticoesteroides/uso terapéutico , Antiinflamatorios/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Colectomía , Colitis Ulcerosa/fisiopatología , Colitis Ulcerosa/cirugía , Ciclosporina/uso terapéutico , Humanos , Inmunosupresores/uso terapéutico , Infliximab , Inyecciones IntravenosasRESUMEN
Crohn's disease is a complex multifactorial disorder characterized by the alternation of a cytokine-driven T-lymphocyte-depending inflammation of the intestinal mucosa, and "off" periods, where patients are completely asymptomatic. Although all the causative factors have not been clearly identified, the continuously growing understanding of the major abnormalities of the inflammatory and immune response leading to the often debilitating symptoms reported by Crohn's disease patients, improves our capacity to characterize new potential therapeutic targets with the subsequent hope to discover new (more efficient and less toxic) drugs. Saying that, in the recent years, tumor necrosis factor-alpha undoubtedly emerges as a key cytokine involved in Crohn's disease pathogenesis, and constant efforts have been made to control tumor necrosis factor-alpha deleterious effects in Crohn's disease. This review schematically summarizes the current understanding of tumor necrosis factor-alpha's role in Crohn's disease pathogenesis as well as the present and the future treatment strategies which may be helpful in patients by inhibiting tumor necrosis factor-alpha production and effects. Beside drugs under investigation, several original approaches are described or mentioned, most of them leading to recent patents such as polyclonal anti-TNF-alpha antibodies from avian origin, allowing potentially oral administration, or combination strategies such as vitamin D and anti-TNF-alpha antibodies or methotrexate and anti-TNF-alpha antibodies, or decoy oligodeoxynucleotides interfering with the binding of nuclear factor-kappaB to its target genes promoters.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Enfermedad de Crohn/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Animales , Anticuerpos Monoclonales/administración & dosificación , Enfermedad de Crohn/inmunología , Quimioterapia Combinada , Humanos , Metotrexato/administración & dosificación , Metotrexato/uso terapéutico , Oligodesoxirribonucleótidos/farmacología , Oligodesoxirribonucleótidos/uso terapéutico , Patentes como Asunto , Factor de Necrosis Tumoral alfa/inmunología , Vitamina D/administración & dosificación , Vitamina D/uso terapéuticoRESUMEN
Protein-energy malnutrition and specific nutrient deficiencies are common in inflammatory bowel diseases (IBD), more particularly in Crohn's disease. In adults, the use of artificial nutrition is indicated in the event of malnutrition, short bowel syndrome, or IBD refractory to all other treatments. In children, enteral nutrition has a place as first-line treatment to avoid side effects of corticosteroids on growth. The use, as a therapeutic tool, of specific nutrients (n-3 fatty acids, glutamine, antioxydant vitamins and minerals, TGF-beta, probiotics...) seems interesting at the pathophysiological level. Nevertheless, these nutrients are still under evaluation and there are not enough available studies to recommend them in clinical routine. A very promising solution is the use of probiotics for the treatment of refractory pouchitis.