Effectiveness of induction therapy with exclusive enteral nutrition in pediatric Crohn's disease / 中国当代儿科杂志

OBJECTIVES@#To evaluate the effectiveness of induction therapy with exclusive enteral nutrition (EEN) in pediatric Crohn's disease (CD).@*METHODS@#A retrospective analysis was performed on the medical data of 62 children with CD who received EEN in Children's Hospital, Zhejiang University School of Medicine, from March 2013 to August 2021. The medical data included general information and height, weight, Pediatric Crohn's Disease Activity Index (PCDAI), Crohn's Disease Endoscopic Index of Severity, C-reactive protein, erythrocyte sedimentation rate, and serum albumin level before treatment and after 8 weeks of treatment. The changes in the above indicators were compared before and after treatment.@*RESULTS@#Among the 62 children with CD, there were 39 boys (63%) and 23 girls (37%), with a mean age of (11.9±3.0) years at diagnosis. Among the 55 children who completed EEN treatment for at least 8 weeks, 48 (87%) achieved clinical remission at week 8. PCDAI at week 8 was significantly lower than that before treatment (P<0.001). Except for 17 children with involvement of the small intestine alone and 3 children with involvement of the colon who did not receive colonoscopy reexamination, the remaining 35 children with involvement of the colon received colonoscopy reexamination after the 8-week EEN treatment. Of the 35 children, 29 (83%) achieved mucosal healing. As for the 48 children who achieved clinical remission at week 8, there were significant improvements in height-for-age Z-score and body mass index-for-age Z-score at week 8 (P<0.01). As for the 7 children who did not achieve clinical remission at week 8, there were no significant changes in height-for-age Z-score and body mass index-for-age Z-score at week 8 (P>0.05).@*CONCLUSIONS@#The 8-week EEN treatment has a good effect on clinical remission and mucosal healing in children with CD. For the children with CD achieving clinical remission, EEN can improve their height and body mass index.

Pediatric metastatic Crohn's disease / Doença de Crohn metastática pediátrica

Crohn's disease (CD) is a chronic, relapsing, idiopathic condition, characterized by granulomatous, transmural inflammation of the gastrointestinal tract, which can affect its entire length, from mouth to anus. Metastatic Crohn's disease (MCD) is a rare form of skin involvement and is defined by skin lesions without contiguity with the gastrointestinal tract. A 9-year-old patient presented with gastrointestinal complaints and gross skin lesions in the vulva and perianal region. The diagnosis of Crohn's disease was made when the patient was 11 years old, after being evaluated by the colorectal surgeon. Treatment was started with a "top-down" approach, with a sustained response for four years. Afterwards, there was a relapse of the skin disease in previously normal areas, without overt symptoms. Treatment consisted of steroids and local infiltration of infliximab, without improvement. A year later, there was a rapid progression of the skin lesions, and the drug changed to adalimumab, also without response and worsening of the skin lesions. The patient was admitted to the hospital and intravenous steroids were initiated, along with surgical debridement of the lesions. After some improvement, ustekinumab was initiated with satisfactory response. Pediatric MCD has an important impact on the patient's quality of life, with influences on growth and social development. (AU)

A doença de Crohn é uma condição idiopática crônica, recidivante, caracterizada por inflamação granulomatosa transmural do trato gastrointestinal, que pode afetar toda a sua extensão, da boca ao ânus. A doença de Crohn metastática (DCM) é uma forma rara que envolve a pele, e é definida por lesões cutâneas sem contiguidade com o trato gastrointestinal. Uma paciente de 9 anos de idade apresentou queixas gastrointestinais e lesões cutâneas grosseiras na vulva e na região perianal. O diagnóstico de doença de Crohn foi feito quando a paciente tinha 11 anos, após avaliação do coloproctologista. O tratamento foi então iniciado com uma abordagem "top-down", com uma resposta mantida por quatro anos. Posteriormente, houve recidiva da doença de pele em áreas anteriormente normais, sem sintomas evidentes. O tratamento consistiu em corticoide e infiltração local de infliximabe, sem melhora. Um ano depois, houve rápida progressão das lesões cutâneas, sendo a medicação alterada para adalimumabe, também sem resposta e com piora das lesões cutâneas. A paciente foi internada e iniciado tratamento com corticoide intravenoso, juntamente com o desbridamento cirúrgico das lesões. Após alguma melhora, o ustecinumabe foi iniciado com resposta satisfatória. A DCM pediátrica tem um impacto importante na qualidade de vida do paciente, com influências no crescimento e no desenvolvimento social. (AU)

Economic burden and factors associated with Crohn's disease / 北京大学学报(医学版)

OBJECTIVE@#To study the economic burden of Crohn's disease and its related factors, and to provide opinions for reducing personal burden and improving reimbursement policy.@*METHODS@#Using a cross-sectional method, a self-created questionnaire based on the basic principles of health services research was used to survey Crohn's disease patients served by the Shanghai volunteer service foundation platform. Information collected included basic characteristics, therapy, and medical costs related to Crohn's disease in the past 12 months. Descriptive statistics were used to analyse the composition of inpatient and outpatient costs of Crohn's disease for treatment of the disease in the past year. Further, a logarithm-linear model was constructed to analyse the factors associated with the financial burden of Crohn's disease.@*RESULTS@#In the study, 820 questionnaires were distributed and 799 questionnaires were returned, of which 797 were valid. There were 528 (66.25%) males and 269 (33.75%) females. The mean age of the patients was (34.02±11.49) years, with a concentration between 18-39 years (510 cases, 63.99%) and a mean disease duration of (5.58±5.13) years. 10.7% of the patients did not receive continuous treatment, and the average annual treatment cost for the patients with continuous treatment was 54 246 Yuan, of which 30 279 Yuan (55.8%) was paid by the individuals and 23 966 Yuan (44.2%) was paid by the insurance. The personal financial burden was close to the national per capita disposable income in 2020, which was 32 189 Yuan (94.1%), exceeding the annual cost for type 2 diabetes in China in 2016, 8 245 Yuan. In terms of the distribution of outpatient and inpatient services, the average annual cost of inpatient services was 31 092 Yuan, of which 14 673 Yuan (48.5%) was paid out of pocket by the individuals and 16 418 Yuan (51.5%) was paid by the insurance; the average annual cost of outpatient services was 23 154 Yuan, of which 15 606 Yuan (65.1%) was paid out of po-cket by the individuals and 7 548 Yuan (34.9%) was paid by the insurance. The personal burden of outpatient care was higher than of inpatient care. The regression results of the logarithm-linear model showed that the total annual treatment cost was related to the duration of illness (β=0.03, P < 0.01), having complications (β=-0.68, P < 0.01), receiving surgical treatment (β=0.52, P < 0.01), using immunosuppressive drugs (β=0.51, P < 0.01), annual outpatient visits (β=0.02, P < 0.05), and number of hospitalizations per year (β=0.08, P < 0.01).@*CONCLUSION@#The annual financial burden for patients with Crohn's disease is heavy and rises significantly with the duration of illness, exceeding that of chronic diseases such as diabetes. The personal financial burden is close to the national per capita disposable income, and the medical security department should develop policies to reduce the financial burden. The inclusion of Crohn's disease as a special outpatient disease is a possible measure that could be considered in response to the fact that the outpatient personal financial burden is heavier than the inpatient's.

Effect of acupuncture-moxibustion on negative emotions and plasma tryptophan metabolism in patients with Crohn's disease at active stage / 中国针灸

OBJECTIVE@#To observe the effect of acupuncture-moxibustion on negative emotions and plasma tryptophan (Trip)-kynurenine (Kyn) metabolism in the patients with Crohn's disease (CD) at the mild and moderate active stage.@*METHODS@#A total of 66 CD patients were randomized into an observation group (33 cases, 1 case dropped off) and a control group (33 cases, 2 cases dropped off). In the observation group, acupuncture was applied in combination with moxibustion. In the control group, the sham-acupuncture was used in combination with sham-moxibustion. In both of the observation group and the control group, acupuncture was applied to Zhongwan (CV 12), Shangjuxu (ST 37), Sanyinjiao (SP 6), Gongsun (SP 4), Hegu (LI 4), Quchi (LI 11), Taixi (KI 3) and Taichong (LR 3), and moxibustion was applied to Tianshu (ST 25) and Zusanli (ST 36). The treatment was given once every two days, 3 times a week, totally for 12 weeks. Separately, before and after treatment, the score of the hospital anxiety-depression scale (HADS) and the score of intestinal core symptoms (degree of abdominal pain and frequency of diarrhea) were observed in the patients of the two groups. The concentration of plasma indoleamine 2,3-dioxygenase 1 (IDO1) and the ratios of Kyn/Trp, QuinA/Kyn, KynA/Kyn and KynA/QuinA were compared between the two groups.@*RESULTS@#Compared with before treatment, the scores of HADS-A and HADS-D in the observation group and the score of HADS-A in the control group were all reduced after treatment (@*CONCLUSION@#Acupuncture and moxibustion relieve the negative emotions of anxiety and depression in CD patients at mild and moderate active stage, which is probably related to the regulation of plasma Trp-Kyn metabolic pathway.

Epidemiología y fenotipo de la enfermedad de Crohn en un hospital de referencia en Lima Perú / Epidemiology and phenotype of Crohn's disease in a reference hospital in Lima Peru

RESUMEN La enfermedad de Crohn (EC) es una patología inflamatoria crónica del tracto digestivo con gran impacto en la calidad de vida de los pacientes. La epidemiología mundial está cambiando en los últimos años y su prevalencia está aumentando en Latinoamérica. Objetivo: Evaluar las características epidemiológicas, fenotipo, curso clínico, diagnóstico y tratamiento de la EC. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo de pacientes con diagnóstico de EC desde enero 2004 a diciembre 2019 en el servicio de gastroenterología del Hospital Nacional Guillermo Almenara Irigoyen, LimaPerú. Resultados: Se incluyó 55 pacientes, con edad promedio de 56 ± 8,2 años. Predominio masculino (62%). El tiempo promedio de diagnóstico fue de 18 ± 6,1 meses. Los síntomas más frecuentes fueron: dolor abdominal 72,7% y baja de peso 60%. Las manifestaciones extraintestinales se presentaron en 20%. La localización ileal (36,4%) fue la más frecuente, seguida de la colónica (32,7%). Predominó el fenotipo inflamatorio en la mitad de los pacientes, seguido de estenosante en 25,5%. La actividad clínica y endoscópica más frecuente fue moderada. Para el tratamiento de inducción y mantenimiento, los corticoides sistémicos y la terapia biológica con anti-TNF fueron los más utilizados respectivamente. Aproximadamente un tercio de pacientes requirieron cirugía durante la evolución de la enfermedad. La mortalidad fue del 5,4%. Conclusiones: La EC es una enfermedad cada vez más frecuente en nuestro país, con características epidemiológicas y fenotípicas que difieren de otros continentes.

ABSTRACT Crohn's disease (CD) is a chronic inflammatory pathology of the digestive tract with great impact on the quality of life of patients. Global epidemiology is changing in recent years and its prevalence is increasing in Latin America. Objective: To evaluate the epidemiological characteristics, phenotype, clinical course, diagnosis and treatment of CD. Materials and methods: Retrospective, descriptive, observational study of patients diagnosed with CD from January 2004 to December 2019 in the gastroenterology service of the Guillermo Almenara Irigoyen National Hospital, Lima-Peru. Results: 55 patients with an average age of 56 ± 8.2 years were included. Male predominance (62%). The average diagnosis time was 18 ± 6.1 months. The most frequent symptoms were: abdominal pain 72.7% and weight loss 60%. Extraintestinal manifestations occurred in 20%. The ileal location (36.4%) was the most frequent, followed by colonic (32.7%). The inflammatory phenotype predominated in half of the patients, followed by stenosing in 25.5%. The most frequent activity clinical and endoscopic was moderate. For induction and maintenance treatment, systemic corticosteroids and biological therapy with anti-TNF were the most widely used, respectively. Approximately a third of patients required surgery during the evolution of the disease. Mortality was 5.4%. Conclusions: CD is an increasingly frequent disease in our country, with epidemiological and phenotypic characteristics that differ from other continents.

Oral and enteral nutrition therapy in inflammatory bowel diseases among the pediatric population: a literature review / Terapia nutricional oral e enteral nas doenças inflamatórias intestinais em crianças e adolescentes: uma revisão de literatura

ABSTRACT Objectives: To review the literature on oral and enteral nutrition therapy and investigate the evidence of its efficacy as a treatment, as well as in preventing relapses and reducing symptoms of inflammatory bowel diseases in the pediatric population. Data source: We performed a bibliographic search in the PubMed, Web of Science, and Latin American and Caribbean Health Sciences Literature (Literatura Latino-Americana e do Caribe em Ciências da Saúde - Lilacs) databases, using the keywords "inflammatory bowel disease," "diet," and "diet therapy" in English and Portuguese, with filters for pediatric studies published in the previous five years. Data summary: We selected 16 articles for this study, nine on exclusive and/or partial enteral nutrition and seven on modified oral diets, such as the specific carbohydrate diet (SCD) and the Crohn's Disease exclusion diet (CDED). The studies found evaluated the anthropometric profile of patients and the inflammatory profile of diseases in children before and after the introduction of each specific nutrition therapy. All interventions presented positive changes in these parameters; however, the results were inconclusive regarding the efficacy of SCD and CDED in the treatment and prevention of relapses. Conclusions: Exclusive enteral nutrition has proven to be effective in inducing remission of Crohn's Disease, and the use of partial enteral nutrition for maintenance treatment has shown promising results. Other modified oral diets are inconclusive concerning their effectiveness, requiring further randomized controlled clinical trials.

RESUMO Objetivos: Revisar a literatura quanto à terapia nutricional oral e enteral e verificar evidências de sua eficácia tanto para tratamento quanto para prevenção de recidivas e redução de sintomas das doenças inflamatórias intestinais em pediatria. Fonte de dados: Foi realizada pesquisa bibliográfica nas bases de dados PubMed, Web of Science e Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) utilizando os seguintes descritores em inglês: inflammatory bowel disease, diet e diet therapy; e os seguintes descritores em português: doenças inflamatórias intestinais e dietoterapia, com os filtros de estudo em Pediatria e no máximo cinco anos de publicação. Síntese dos dados: Foram selecionados 16 artigos para este estudo, sendo nove sobre o uso de nutrição enteral exclusiva e/ou parcial e sete sobre modificações da dieta oral, como a dieta específica de carboidratos (SCD) e a dieta de exclusão na Doença de Crohn (CDED). Os estudos encontrados avaliaram o perfil antropométrico dos pacientes e o perfil inflamatório das doenças em crianças antes e depois da introdução de cada terapia nutricional específica. Em todas as intervenções, foram observadas mudanças positivas nesses parâmetros, entretanto os resultados mostraram-se inconclusivos em relação à eficácia da SCD e da CDED no tratamento e na prevenção de recidivas. Conclusões: A nutrição enteral exclusiva mostrou-se uma terapia eficaz para a indução da remissão na Doença de Crohn, e o uso da nutrição enteral parcial para tratamento de manutenção vem exibindo resultados promissores. As demais modificações de dietas orais são inconclusivas a respeito de sua eficácia, sendo necessários mais ensaios clínicos randomizados e controlados.

Vedolizumabe no manejo das doenças inflamatórias intestinais: um estudo multicentrico observacional brasileiro / Vedolizumab in the management of inflammatory bowel diseases: a brazilian observational multicentric study

ABSTRACT BACKGROUND: There is scarce data regarding efficacy and safety of vedolizumab in inflammatory bowel diseases in Latin America. OBJECTIVE: To describe the first observational real-world experience with vedolizumab in Latin American inflammatory bowel diseases patients. METHODS: Retrospective observational multicentric study of patients with Crohn's disease (CD) and ulcerative colitis (UC) who used vedolizumab at any phase of their treatment. Clinical remission and response (according to Harvey-Bradshaw index for CD and Mayo score for UC), mucosal healing, need for surgery and adverse events were evaluated. RESULTS: A total of 90 patients were included (52 with CD and 38 with UC), the majority with previous exposure to anti-TNF agents (88.46% in CD and 76.31% in UC). In CD (as observed analysis) remission rates at weeks 12, 26 and 52 were 42.89% (21/49), 61.9% (26/42) and 46.15% (12/26), respectively. In UC, remission rates at weeks 12, 26 and 52 were 28.94% (11/38), 36.66% (11/30) and 41.17% (7/17). Mucosal healing rates were 36.11% in CD and 43.4% in UC. During the study period, 7/52 CD patients underwent major abdominal surgery and 4/38 UC patients needed colectomy. CONCLUSION: Vedolizumab was effective in induction and maintenance of clinical response and remission in CD and UC, with no new safety signs.

RESUMO CONTEXTO: Há escassez de dados sobre a eficácia e segurança do vedolizumabe nas doenças inflamatórias intestinais na América Latina. OBJETIVO: Descrever a primeira experiência observacional de mundo real com vedolizumabe em pacientes latino-americanos com doenças inflamatórias intestinais. MÉTODOS: Estudo retrospectivo multicêntrico observacional de pacientes com doença de Crohn (DC) e retocolite ulcerativa inespecífica (RCUI) que utilizaram vedolizumabe em qualquer fase de seu tratamento. Foram avaliadas a remissão e resposta clínicas (de acordo com o índice de Harvey-Bradshaw para DC e escore de Mayo para RCUI), cicatrização da mucosa, necessidade de cirurgia e eventos adversos. RESULTADOS: Foram incluídos 90 pacientes (52 com DC e 38 com RCUI), a maioria com exposição prévia a agentes anti-TNF (88,46% na DC e 76,31% na RCUI). Na DC (em análise conforme observado), as taxas de remissão nas semanas 12, 26 e 52 foram 42,89% (21/49), 61,9% (26/42) e 46,15% (12/26), respectivamente. Na RCUI, as taxas de remissão nas semanas 12, 26 e 52 foram de 28,94% (11/38), 36,66% (11/30) e 41,17% (7/17). As taxas de cicatrização da mucosa foram 36,11% na DC e 43,4% na RCUI. Durante o período do estudo, 7/52 pacientes com DC foram submetidos a cirurgia abdominal maior e 4/38 pacientes com RCUI necessitaram de colectomia. CONCLUSÃO: O vedolizumabe foi eficaz na indução e manutenção da resposta e remissão clínicas em população refratária na DC e RCUI, com perfil de segurança favorável.

Papel de la medicina regenerativa y los sellantes en la enfermedad de Crohn perianal / Role of regenerative medicine and sealants in perianal Crohn's disease

La enfermedad de Crohn constituye una enfermedad inflamatoria crónica que puede cursar con fistulas complejas en hasta un 20% de los pacientes. A pesar de la intensificación del tratamiento, asociado o no a la cirugía, todavía es considerable el porcentaje de pacientes que no responden al tratamiento. En los últimos años se ha empezado a desarrollar nuevas terapias que permitan conseguir una mayor tasa de curación de estos pacientes, con las mínimas complicaciones posibles. Es cuando aparecen agentes que pretenden de forma directa el sellado o intervienen en la reducción local de la inflamación. Es objetivo de este artículo mostrar el papel de la Medicina Regenerativa en el tratamiento de estos pacientes.

Crohn's disease is a chronic inflammatory disease that can occur with complex fistulas in up to 20% of patients. Despite the intensification of treatment, associated with no surgery, the percentage of patients who do not respond to treatment is still considerable. In recent years, new therapies have been developed to achieve a higher cure rate for these patients, with the minimum possible complications. It is when agents appear to pretend as seal fistula tract as the local reduction of inflammation. The aim of this article is to show the role of Regenerative Medicine in the treatment of these patients.

Terapia biológica na doença de Crohn: quando iniciar? / Biologic therapy for Crohn's disease: when to initiate?

A doença de Crohn se caracteriza como uma doença inflamatória, que acomete qualquer porção do trato gastrintestinal, resultante da desrregulação imunológica, gerenciada por fatores endógenos e exógenos. As formas de abordagem terapêutica da doença variam conforme sua apresentação clínica e gravidade, bem como o impacto na qualidade de vida do portador. A terapia biológica vem se tornando uma das principais classes utilizadas no contexto desta enfermidade, mas não está claro quando deve ser iniciada ou em que momento a própria doença deve ser considerada moderada ou grave. Sua forma de apresentação multiforme dificulta a classificação dos pacientes nestes grupos. Neste trabalho, foi realizada revisão de literatura sobre a introdução de terapia biológica como tratamento da doença inflamatória intestinal em curso. (AU)

Crohn's Disease (CD) is an inflammatory disease that can affect any portion of the gastrointestinal tract, caused by immune dysregulation, managed by endogenous and exogenous factors. The forms of therapeutic approach of the disease vary significantly according to its clinical presentation and severity, as well as to the impact on patient's quality of life. Biologic therapy has become one of the main classes used in the context of this disease; however, when it should be initiated or at what time the disease itself should be considered moderate or severe is not clear. Its multiform presentation makes it difficult to classify patients in these groups. In this work, a literature review was carried out about the introduction of the biologic therapy as a treatment of the ongoing inflammatory bowel disease. (AU)

Transplantation of adipose-derived mesenchymal stem cells in refractory crohn's disease: systematic review / Transplante de células-tronco mesenquimais derivadas do tecido adiposo na doença de crohn refratária: revisão sistemática

ABSTRACT Background: Crohn's disease is a pathological condition that has different options of treatment, but there are patients who need other therapeutic approach, such as the use of adipose-derived mesenchymal stem cells. Aim: Systematic literature review to determine the different ways of adipose-derived mesenchymal stem cells administration in humans with luminal refractory and perianal fistulizing Crohn's disease. Methods: It was conducted a search for articles (from 2008 to 2018) on PubMed and ScienceDirect databases using the keywords Crohn's disease, fistulizing Crohn's disease, luminal Crohn's disease and transplantation of mesenchymal stem cells or mesenchymal stem cells or stromal cells. Thirteen publications were selected for analysis. Results: Only one study referred to the luminal Crohn´s disease. The number of cells administered was variable, occurring mainly through subcutaneous adipose tissue by liposuction. It could be highlighted the autologous transplant with exclusive infusion of mesenchymal stem cells. The procedures involved in pre-transplant were mainly curettage, setons placement and stitching with absorbable suture, and conducting tests and drug treatment for luminal Crohn´s disease. During transplant, the injection of mesenchymal stem cells across the fistula path during the transplant was mainly on the intestinal tract wall. Conclusion: Although the use of mesenchymal stem cells is promising, the transplant on the luminal region should be more investigated. The injection of mesenchymal stem cells, exclusively, is more explored when compared to treatment with other products. The preparation of the fistulizing tract and the location of cell transplantation involve standardized health care in most studies.

RESUMO Racional: Há diferentes opções de tratamento para a doença de Crohn, porém, em alguns casos, há a necessidade de outras abordagens terapêuticas, como o uso de células-tronco mesenquimais derivadas do tecido adiposo. Objetivo: Revisar sistematicamente a literatura para determinar as diferentes formas de administração das células-tronco mesenquimais derivadas do tecido adiposo em seres humanos com doença de Crohn refratária luminal e fistulizante perianal. Método: Buscaram-se artigos publicados entre 2008 e 2018 nas bases de dados PubMed e ScienceDirect, pelos descritores: Crohn's disease, fistulizing Crohns disease, luminal Crohns disease e transplantation of mesenchymal stem cells ou mesenchymal stem cell ou stromal cells. Treze artigos foram selecionados. Resultados: Somente um trabalho se referiu à doença luminal. A quantidade de células administradas foi variável, obtendo-se principalmente do tecido adiposo subcutâneo por lipoaspiração. Destacou-se o transplante autólogo com a infusão exclusiva de células-tronco mesenquimais. Os procedimentos realizados no pré-transplante foram principalmente o de curetagem, colocação de setons e suturas com fio absorvível, e de exames e tratamento medicamentoso para a doença luminal. No transplante, ocorreu a injeção das células por todo o trajeto fistuloso, principalmente nas paredes do trato. Conclusão: Embora o uso de células-tronco mesenquimais seja promissor, o transplante na região luminal deve ser mais investigado. A injeção exclusiva de células-tronco mesenquimais é mais explorada quando comparada ao tratamento conjunto com outros produtos. A forma de preparo do trato fistuloso e o local de transplante envolvem cuidados médicos padronizados na maioria dos estudos.

Certolizumabe pegol para o tratamento da doença de Crohn moderada a grave / Certolizumab pegol for the treatment of moderate to severe Crohn's disease

Contexto: A doença de Crohn (DC) é uma doença inflamatória crônica intestinal, caracterizada por inflamação focal, assimétrica, transmural e, ocasionalmente, granulomatosa. Afeta principalmente o trato gastrointestinal, sendo o íleo, cólon e região perianal as regiões mais acometidas. Apresenta-se em estágios bem definidos, a saber: remissão clínica, leve a moderada, moderada a grave e grave ou fulminante. O SUS oferece tratamento para a DC, preconizado por Protocolo Clínico e Diretrizes Terapêuticas (PCDT) para essa condição. Os pacientes com DC moderada a grave devem iniciar o tratamento com corticosteroides, azatioprina, alopurinol ou metotrexato. Em caso de falha terapêutica ou intolerância aos esquemas terapêuticos inicialmente recomendados, deve-se introduzir então, os agentes anti-TNF. Nesse contexto, o demandante solicitou a incorporação do certolizumabe pegol no tratamento da DC moderada a grave, na mesma etapa de tratamento dos agentes anti-TNF já incorporados no SUS. Pergunta: O uso do certolizumabe pegol é eficaz, seguro e custo-efetivo em pacientes com doença de Crohn moderada a grave, com resposta inadequada ou contraindicação ao tratamento convencional quando comparado aos agentes anti-TNF adalimumabe ou infliximabe? Evidências científicas: Foram apresentadas revisões sistemáticas com metanálise de comparação indireta para os desfechos de eficácia e, revisão sistemática e estudo clínico aberto para as evidências de segurança. Os estudos concluíram que não há diferença significativa entre os agentes anti-TNF certolizumabe pegol, adalimumabe e infliximabe nos desfechos de indução e manutenção de remissão, assim como resposta clínica. Entretanto, os rankings de probabilidade sugerem o certolizumabe pegol como um tratamento menos efetivo que os demais em diferentes desfechos. Quanto aos desfechos de segurança, observa-se que para os três agentes anti-TNF estudados, a taxa de eventos adversos é importante, mas se mantém ao longo dos anos de acompanhamento. Ademais, em relação ao risco de infecções graves, o certolizumabe pegol apresentou risco semelhante, comparado ao adalimumabe e infliximabe. Avaliação econômica: Foi realizada uma avaliação econômica com um modelo de custo-minimização. Para a realização dos cálculos, foram considerados somente os custos de aquisição dos medicamentos. Os resultados demonstram que o certolizumabe pegol é 40% a 50% menos custoso que o adalimumabe e \r\no infliximabe, tanto no primeiro ano de tratamento quanto nos demais anos. Avaliação de Impacto Orçamentário: O demandante calculou o impacto orçamentário em um cenário base que considera uma divisão de mercado (market share) gradual de até 20% em 2021, considerando uma perspectiva de horizonte temporal de 5 anos. A quantidade de pacientes elegíveis foi estimada utilizando dados do \r\nDATASUS de pacientes portadores de DC que fazem uso de infliximabe ou adalimumabe. Os custos de tratamento considerados foram aqueles referentes ao tratamento de indução e manutenção e os preços já utilizados nas compras do ministério da saúde. O impacto orçamentário resultante da incorporação do certolizumabe pegol seria de economia de aproximadamente 60,3 milhões de reais em 5 anos após a incorporação. Discussão: Os resultados apresentados sugerem que o certolizumabe pegol é tão eficaz e \r\nseguro quanto o infliximabe e o adalimumabe. Ademais, os gastos com medicamentos biológicos serão potencialmente reduzidosno cenário de incorporação desse agente. Decisão: Incorporar o certolizumabe pegol para o tratamento da doença de Crohn moderada a grave, conforme Protocolo Clínico e Diretrizes Terapêuticas \r\ndo Ministério da Saúde, no âmbito do Sistema Único de Saúde - SUS. A decisão foi dada pela Portaria SCTIE\r\n-MS nº 1publicada no Diário Oficial da União (DOU) nº 4, de 5 de janeiro de 2017. A Portaria Nº 1, de 4 de janeiro de 2017 - Torna pública a decisão de incorporar o certolizumabe pegol para o tratamento da doença de Crohn moderada a grave, conforme Protocolo Clínico e Diretrizes Terapêuticas do Ministério da Saúde, no âmbito do Sistema Único de Saúde - SUS.

Educación al paciente con enfermedad inflamatoria intestinal: impacto de un equipo multidisciplinario / Education to IBD patients: impact of a multidisciplinary team

Inflammatory bowel disease (IBD) is a chronic, idiopathic disease characterized by inflammation of the gastrointestinal tract. It affects more than 5 million people worldwide and in Chile studies suggest that IBD incidence has increased in recent years. It is manifested by periods of remission and activity, requiring permanent pharmacological treatment. Both, the occurrence of a crisis episode and the need for lifetime medical treatment could affect the quality of life of IBD patients. Studies suggest that patients with IBD require education to develop self-management of their disease and adhere to treatment, thus reducing the risk of crisis episodes. The importance of this strategy or action is significant if we consider that studies have shown that the level of knowledge of IBD patients regarding their pathology is low. The purpose of this article is to review the effect of education on the management of IBD patients and the implications of a multidisciplinary team with an IBD specialist nurse.

La enfermedad inflamatoria Intestinal (EII) es una enfermedad crónica, idiopática, caracterizada por la inflamación del tracto gastrointestinal. Afecta a más de 5 millones de personas en el mundo y en Chile estudios sugieren que ha ido en aumento en los últimos años. Se manifiesta por períodos de remisión y actividad, siendo necesario un tratamiento farmacológico permanente. Tanto la presencia de crisis como la necesidad de un tratamiento médico de por vida, podrían afectar la calidad de vida de estos pacientes. Estudios sugieren que los pacientes con EII requieren de educación para poder desarrollar un buen autocuidado de su enfermedad, adherirse al tratamiento y disminuir así el riesgo de crisis. Esta estrategia o acción no deja de ser importante si consideramos que estudios han mostrado que el nivel de conocimiento de los pacientes con EII respecto a su patología es bajo. El propósito de este artículo es revisar el efecto de la educación en el manejo de los pacientes con EII, y las implicancias de un equipo multidisciplinario con una enfermera especialista en EII que realice el seguimiento de estos pacientes.

Therapies for crohn's disease: a clinical update / Terapia farmacológica em portadores de doença de Crohn. Atualização clínica

ABSTRACT The main objectives of clinical therapy in Crohn's disease are clinical and endoscopic remission without the use of corticosteroids for long periods of time, prevention of hospitalization and surgery, and improvement of quality of life. The main limitation of drug therapy is the loss of response over the long term, which makes incorporation of new drugs to the therapeutic arsenal necessary. This review analyses the main drugs currently used in clinical treatment of Crohn's disease.

RESUMO Os principais objetivos da terapia clínica na doença de Crohn são a remissão clínica e endoscópica por tempo prolongado, sem o uso de corticosteroides, além de evitar hospitalizações e cirurgias, e melhorar a qualidade de vida. A principal limitação da terapêutica medicamentosa é a perda de reposta a longo prazo, o que faz com que a incorporação de novas drogas ao arsenal terapêutico seja necessária. Esta revisão aborda os principais medicamentos utilizados atualmente no tratamento clínico da doença de Crohn.

Enfermedad de Crohn: experiencias de vivir con una cronicidad / Crohn's disease: The experience of living with a chronic illness

Objetivo. Explorar las experiencias de personas con enfermedad de Crohn (EC), aquellos acontecimientos que modificaron sus vidas, el impacto y las estrategias utilizadas para sobrellevar la enfermedad. Material y métodos. Estudio cualitativo. Se realizaron 10 entrevistas a profundidad a afectados de la provincia de Alicante (España). La recolección de datos, procesamiento y análisis de los mismos se realizó a través de algunos elementos que recoge la fenomenología. Resultados. Las experiencias de los afectados se pueden clasificar en cuatro grandes temas: reconocimiento de enfermar, consecuencias percibidas por los afectados por EC de la propia enfermedad, gestión de la enfermedad y búsqueda de apoyo. Conclusiones. El conocimiento de la experiencia de vida de las personas afectadas por EC parece una herramienta indispensable para conseguir una gestión eficaz del proceso de cronicidad al momento de planificar programas sanitarios específicos de tratamiento.

Objective. To explore the experiences of people with Crohn disease (CD), their life-changing events, the impact on their lives and the strategies used to cope with it. Materials and Methods. Qualitative study. In-depth interviews were carried out on 10 people affected by the disease in the province of Alicante (Spain). The collection, processing and analysis of data was performed using some phenomenological elements. Results. The experiences of those affected can be classified into four main areas: recognition of the illness; perceived consequences of the disease itself by CD affected patients; disease management, and the search for support. Conclusions. Knowledge of the life experience of people affected by CD appears to be essential for the effective management of chronic illnesses when planning specific health treatment programs.

Tratamiento con infliximab o adalimumab en la Enfermedad de Crohn grave o Enfermedad de Crohn con fístulas perianales complejas / Treatment with infliximab or adalimumab in severe Crohn's disease or Crohn's disease with complex perianal fistulas

Entregar orientaciones a los equipos de salud para estandarizar el manejo clínico farmacológico en el tratamiento con medicamentos biológicos para la Enfermedad de Crohn grave corticorefractarios o inmunorefractarios.Entregar orientaciones para el manejo clínico farmacológico en el tratamiento con medicamentos biológicos en pacientes con Enfermedad de Crohn grave o con Enfermedad de Crohn con fístulas perianales complejas. Dirigido a profesionales multidisciplinarios del equipo de salud que atienden personas con Enfermedad de Crohn grave o con Enfermedad de Crohn con fístulas perianales complejas. Población del objetivo - adultos y niños con diagnóstico de Enfermedad de Crohn grave o con Enfermedad de Crohn con fístulas perianales complejas. La garantía explícita de protección financiera para el tratamiento biológico para la Enfermedad de Crohn grave o con fístulas perianales complejas comprende el tratamiento con Infliximab o Adalimumab. Seguimiento: Enfermedad de Crohn Grave y Enfermedad de Crohn con fístulas perianales complejas: El seguimiento de los pacientes puede ser realizado por médicos gastroenterólogos, (adulto o pediátrico según corresponda) o coloproctólogo. También podrá ser realizado por médicos que no tienen la especialidad de gastroenterología, pero cuentan con capacitación o con experiencia en el manejo de estos pacientes, los que deberán ser autorizados por el Comité de Expertos.

Adjunctive Hyperbaric Oxygen Therapy promotes successful healing in patients with refractory Crohn's disease

PURPOSE: To investigate de adjunctive effect of Hyperbaric Oxygen Therapy in a group of patients with refractory Crohn's disease. METHODS: A total of 29 subjects with refractory Crohn's disease were submitted to daily sessions of Hyperbaric Oxygen Therapy, in a 2800 Sechrist Monoplace Hyperbaric Chamber (Sechrist, USA) pressurized to 2.4 ATA. Each session lasted 2 hours. The endpoint was closure of enterocutaneous fistulas and complete healing of Pyoderma Gangrenosum and perineal Crohn's disease. RESULTS: A total of 829 HBOT sessions were performed and no complications were noted. Overall success rate was 76% (22 cases). Pyoderma Gangrenosum and enterocutaneous fistulas had the highest successful healing rates (100% and 91%, respectively). Perineal Crohn's disease healing rate was 65%. CONCLUSION: Adjunctive Hyperbaric Oxygen Therapy promoted satisfactory healing in a group of patients with refractory Crohn's disease.

Doença inflamatória intestinal na infância / Intestinal Inflamatory disease in childood

A incidência da doença inflamatória intestinal (DII) tem aumentado nos países ocidentais nos últimos anos. Classicamente ela é dividida em doença de Crohn e colite ulcerativa. As manifestações clínicas mais comuns são a dor abdominal, diarreia, perda de peso e sangue nas fezes. A inflamação intestinal reduz a absorção de nutrientes. Manifestações extraintestinais podem estar presentes. Deve ser realizada a pesquisa de imunodeficiência primária em crianças com diagnóstico de DII antes dos dois anos de idade. Os exames laboratoriais devem incluir triagem de inflamação aguda e/ou crônica, avaliação de anemia e estado nutricional. Exames endoscópicos e de fezes são necessários, principalmente antes do início do tratamento. O seguimento ambulatorial e a solicitação de exames complementares devem ser criteriosos. O tratamento é difícil por se tratar de uma doença crônica, com fases de recidiva e remissão. Os medicamentos apresentam efeitos adversos, algumas vezes graves. A visão mais atual da terapia da DII baseia-se na modificação da história natural da doença, com o objetivo de alcançar cicatrização da mucosa, redução das complicações da doença e melhora da qualidade de vida do paciente. É fundamental acompanhar o crescimento linear, o desenvolvimento muscular, esquelético e puberal. O pediatra geral deve estar atento para o diagnóstico, solicitando os exames complementares e avaliando a necessidade de encaminhamento para um gastroenterologista pediatra.(AU)

The incidence of inflammatory bowel disease in the Western countries has increased in recent years. Classically it is divided into Crohn's Disease and Ulcerative Colitis. The most common clinical manifestations are abdominal pain, diarrhea, weight loss and blood in the stool. The intestinal inflammation reduces the absorption of nutrients, which increases susceptibility to micronutrient deficiency. extra-intestinal manifestations may be present. Primary immunodeficiency research in children diagnosed with IBD before two years of age should be performed. Laboratory tests should include screening of acute and/or chronic, evaluation of anemia and nutritional status. Endoscopic examinations and feces are needed, especially before the start of treatment. Outpatient follow-up and complementary tests should be judicious. Treatment is difficult because it is a chronic disease with phases of relapse and remission. The drugs have adverse effects sometimes severe. The most current view of IBD therapy is based on the modification of the natural history of the disease, with the goal of achieving mucosal healing, reducing complications of the disease and improve the patient's quality of life. It is essential to monitor the linear growth, muscle development, skeletal and pubertal. The general pediatrician should be aware of the diagnosis, requesting additional examinations and evaluating the need for referral to the pediatric gastroenterologist.(AU)

Therapeutic Efficacy of Oral Enteral Nutrition in Pediatric Crohn's Disease: A Single Center Non-Comparative Retrospective Study

PURPOSE: Exclusive enteral nutrition (EEN) therapy effectively induces clinical remission in Crohn's disease (CD). It remains unclear, however, whether partial enteral nutrition (PEN) can maintain remission. This study was performed to determine the abilities of oral EEN and oral PEN to induce and maintain clinical remission in pediatric patients with CD, respectively. MATERIALS AND METHODS: Pediatric patients with CD who received oral EEN at a single center in 2000-2014 were identified retrospectively. Remission rates of the EEN and PEN during the 2 years study period were determined. Risk factors for EEN and PEN failure were identified. RESULTS: Of the 66 patients who started EEN, 61 (92%) completed the course. Clinical remission was achieved in 88% (58/66) of the patients. All 58 patients with remission continued with PEN: 43 (74%) were treatment adherent. The cumulative remission rates at 1 and 2 years were 67% and 52%, respectively. Differing from EEN, limited therapeutic efficacy of PEN was shown in severe CD patients. Female gender associated significantly with non-adherence. CONCLUSION: Oral EEN and PEN effectively induced and maintained remission in a pediatric population. Non-adherence was a limiting factor in the success of therapy.