Scientific Letter
Duration of sustained remission after treatment by induction with exclusive enteral nutrition and azathioprine in patients with Crohn’s disease
Duración de la remisión sostenida tras el tratamiento de inducción con nutrición enteral exclusiva y azatioprina en pacientes con enfermedad de Crohn
Alicia Isabel Pascual Pérez
, Gemma Pujol Muncunill, Patricia Domínguez Sánchez, Sara Feo Ortega, Javier Martín de Carpi
Corresponding author
Unidad para el Cuidado Integral de la Enfermedad Inflamatoria Intestinal Pediátrica (UCIEII-P), Servicio de Gastroenterología, Hepatología y Nutrición Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
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"autores" => array:5 [ 0 => array:4 [ "nombre" => "Alicia Isabel" "apellidos" => "Pascual Pérez" "email" => array:2 [ 0 => "aliciapascual13@gmail.com" 1 => "aliciapascual.pediatrics@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Gemma" "apellidos" => "Pujol Muncunill" ] 2 => array:2 [ "nombre" => "Patricia" "apellidos" => "Domínguez Sánchez" ] 3 => array:2 [ "nombre" => "Sara" "apellidos" => "Feo Ortega" ] 4 => array:2 [ "nombre" => "Javier" "apellidos" => "Martín de Carpi" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad para el Cuidado Integral de la Enfermedad Inflamatoria Intestinal Pediátrica (UCIEII-P), Servicio de Gastroenterología, Hepatología y Nutrición Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Duración de la remisión sostenida tras el tratamiento de inducción con nutrición enteral exclusiva y azatioprina en pacientes con enfermedad de Crohn" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1360 "Ancho" => 2248 "Tamanyo" => 233228 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study results.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Numerous studies have evinced the efficacy of exclusive enteral nutrition (EEN) to induce remission in paediatric-onset Crohn’s disease (POCD).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The guidelines of the European Crohn's and Colitis Organization and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ECCO-ESPGHAN) recommend the use of EEN combined with early initiation of immunosuppression in patients with mild to moderate forms of disease.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, there are no data on the long-term efficacy of this strategy in preventing or postponing the use of biological therapy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Thus, to determine the proportion of our patients with POCD that require initiation of anti-tumour necrosis factor (TNF) therapy after achieving clinical remission with the aforementioned approach, we conducted the observational retrospective study presented in this article.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We reviewed the medical records of patients with POCD that were diagnosed in our unit between 2003 and 2017 and achieved clinical remission at onset with a combination of EEN and thiopurine drug therapy (azathioprine, mercaptopurine). We collected demographic, clinical and outcome data for these patients until February 2019 or their transition to the adult care unit.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We included 91 patients (68.1% male; mean age at onset, 12.29 years, median age, 13 years; age range, 8 months–17 years) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The mean duration of follow-up of patients in our unit was 60.45 months (range, 8–165 months). During this time, 66 of the 91 patients (72.53%) relapsed. The strategy used to manage the relapse in 17 patients (25.76%) was a second cycle of EEN, which was effective in 7 of them (41.18%). The mean time elapsed from diagnosis to the second cycle of EEN was 13.76 months (maximum, 110 months). During the follow-up, 65.6% of the patients required escalation of treatment to anti-TNF therapy due to failure of maintenance with thiopurines, with a mean time elapsed from onset to initiation of anti-TNF therapy of 15.29 months (median, 9 months). Of all patients that required biological therapy, 72.9% started with adalimumab (ADA). After a period of combined treatment (anti-TNF and thiopurines), the immunosuppressive treatment was discontinued in 42.2% of patients once they exhibited sustained clinical and endoscopic remission, thus switching to anti-TNF as monotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Despite the limitations intrinsic in the retrospective design of the study, the results obtained in a large sample of patients (<span class="elsevierStyleItalic">n</span> = 91 patients) show that although EEN is an effective approach for induction of remission in POCD, a successful-enough approach has yet to be established for subsequent maintenance to prevent the need of biological therapy in the medium term in a significant proportion of patients. Such an approach should involve more strict criteria for the definition of remission and a thorough evaluation of the latter so enable the establishment of more appropriate maintenance therapy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">This study did not receive any funding.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pascual Pérez AI, Pujol Muncunill G, Domínguez Sánchez P, Feo Ortega S, Martín de Carpi J. Duración de la remisión sostenida tras el tratamiento de inducción con nutrición enteral exclusiva y azatioprina en pacientes con enfermedad de Crohn. An Pediatr (Barc). 2021;94:252–253.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Previous presentation: This study was presented and received the award to the best brief oral communication in Gastroenterology/Nutrition at the XXVI Congress of the Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica; May 16–18, 2019; Santander, Spain.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1360 "Ancho" => 2248 "Tamanyo" => 233228 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exclusive enteral nutrition continues to be first line therapy for pediatric Crohn’s disease in the era of biologics" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.M. 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| 2022 April | 34 | 37 | 71 |
| 2022 March | 47 | 47 | 94 |
| 2022 February | 40 | 30 | 70 |
| 2022 January | 47 | 25 | 72 |
| 2021 December | 45 | 38 | 83 |
| 2021 November | 46 | 33 | 79 |
| 2021 October | 67 | 75 | 142 |
| 2021 September | 30 | 32 | 62 |
| 2021 August | 44 | 42 | 86 |
| 2021 July | 36 | 35 | 71 |
| 2021 June | 91 | 29 | 120 |
| 2021 May | 48 | 48 | 96 |
| 2021 April | 362 | 188 | 550 |
| 2021 March | 69 | 41 | 110 |
| 2021 February | 54 | 23 | 77 |
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