Does Adjuvant Nutritional Support Diminish Steroid Dependency in Crohn Disease? Verma S, Holdsworth CD, Giaffer MH. Scand J Gastroenterol 2001;36:383–8.
Verma et al. studied the impact of enteral nutritional supplementation on 33 adults with steroid-dependent Crohn disease who were in remission. The patients were randomized to receive either an elemental diet (E028 Extra, n = 19) or a polymeric diet (Fortisip, n = 14). Supplements were given orally in addition to a normal diet to provide 35% to 50% of pretrial total calorie intake. Prednisolone was withdrawn gradually. Patients were observed for 12 months. Treatment failure was defined as an increase in Crohn disease activity index by 100 points from the baseline to more than 200 points, the inability to withdraw chronic steroid therapy completely, and the need for surgery or steroid therapy. Nutritional supplementation was successful in 43% of all patients (14/33), who remained in remission for 12 months with complete withdrawal of steroids. The response to the elemental diet (42%) was similar to that of the polymeric diet (43%). Nutritional supplementation failed in 13 (39%). Six (18%) patients did not tolerate enteral feeding because of smell and taste. Protocol analysis of data showed that the success rate of nutritional supplements in patients who were steroid-dependent was 52% (14 of 27 patients). No disease-or patient-related factors helped predict the response to enteral nutritional supplements.
Anthony K. Akobeng
Department of Paediatric Gastroenterology
Central Manchester and Manchester Children's
Booth Hall Children's Hospital
Manchester, United Kingdom
Enteral nutrition is effective in inducing remission in active Crohn disease (J Pediatr Gastroenterol Nutr 2000;31:3–5;J Pediatr Gastroenterol Nutr 1993;17:75–81). However, its role in preventing relapses during periods of remission has not been explored widely. Verma et al. reported the successful use of long-term enteral nutritional supplementation in allowing complete steroid withdrawal and maintaining remission in about half of patients with steroid-dependent Crohn disease. The implications of these findings are particularly relevant for the pediatric population in whom steroid use may be associated with worrying complications such as growth failure (Paediatr Drugs 2000;2:193–203) and osteopenia (Arch Dis Child 1997;76:325–9).
Recent studies, mainly from the adult literature, suggest that long-term enteral nutritional supplementation and an unrestricted normal diet may prolong remission and decrease relapse rates in patients with Crohn disease (Dig Liver Dis 2000;32:769–74;Nippon Shokakibyo Gakkai Zasshi 1993;90:2882–8). In an earlier study, Verma et al. (Dig Liver Dis 2000;32:769–74) investigated the role of supplementing a normal diet with an elemental diet in long-term management of Crohn disease. They studied 39 consecutive patients who were in clinical remission. Of these, 21 (Group 1) received oral nutritional supplements in addition to their normal diets whereas 18 patients (Group 2) were maintained on a normal unrestricted diet. The patients were observed for 12 months. A total of 17 patients (81%) tolerated the nutritional supplements. In an intention-to-treat analysis, 10 patients in Group 1 (10/21,48%) remained in remission for 12 months, compared with 4/18 (22%) patients in Group 2, P h 0.0003.
In 1993, Koga et al. (Nippon Shokakibyo Gakkai Zasshi 1993;90:2882–8) reported that the use of a low-residue diet (Clinimeal or Ensure liquid) was useful for maintaining remission in patients with Crohn disease and that the beneficial effect seemed to depend on the quantity of the diet given each day. Earlier in 1983, Harries et al. (Lancet 1983;1:887–90) reported a beneficial effect of long-term oral dietary supplementation (Ensure Plus) in improving nutritional status and decreasing disease activity in patients with Crohn disease.
Formal studies investigating the role of long-term supplementation of a normal diet with enteral nutrition in children with Crohn disease are limited. However, in 1996, Wilschanski et al. (Gut 1996;38:543–8) reported a retrospective study in which children and adolescents with Crohn disease who were treated successfully with exclusive enteral nutrition and were classified retrospectively according to whether they continued supplementary enteral nutrition. Enteral nutrition was provided as overnight nasogastric feeds. Time to relapse and linear growth were compared between the two cohorts. Relapse rates at 6 months (15 of 19 versus 5 of 28, P h 0.001), and at 12 months (15 of 19 versus 12 of 28, P h 0.02) were higher in the control cohort than in the cohort receiving nocturnal supplements. Enteral nutritional supplementation was also associated with better linear growth.
The exact role of nutritional therapy in modulating the inflammatory process in Crohn disease is uncertain. Several mechanisms have been proposed, but none has been proven as the primary mode of action (Med Clin N Am 1994;78:1443–57). These include providing essential nutrients, decreasing the antigenic effect of food proteins, altering bowel flora, and improving immune function. Fell et al. (Aliment Pharmacol Ther 2000;14:281–9) recently showed that clinical response to enteral nutrition in children with active intestinal Crohn disease was associated with mucosal healing and down-regulation of mucosal proinflammatory cytokine mRNA in the terminal ileum and colon. Earlier in 1995, Breese et al. (Aliment Pharmacol Ther 1995;9:547–52) also reported that enteral nutrition was associated with the down-regulation of lymphokine secretion in the gut of children with Crohn disease.
Verma et al. and other related studies suggest that long-term enteral nutritional supplementation may play a useful role in maintaining remission in Crohn disease. This is an attractive proposition for the pediatric population because it may help minimize use of steroids and immunosuppressive agents, thereby avoiding some of the complications of these medications.