An overview of a presentation by Professor Geneviève Veereman-Wauters from Children's Hospital, Belgium, at the Raising Expectations in Gastroenterology symposium, 2011.
Conventional management of Crohn's disease in adults and children is based on a 'step-up' approach to treatment, with corticosteroids used in acute management, followed by immunosuppressants. While favourable short-term remission rates have been reported with corticosteroids, long-term remission is often incomplete.1 In addition, there are considerable risks associated with corticosteroid use.
A landmark study showed the addition of 6-mercaptopurine to corticosteroids could reduce the need for prednisone and help sustain remission in children with newly-diagnosed Crohn's disease.2 This has encouraged the utilisation of 6-mercaptopurine or azathioprine as initial therapy alongside corticosteroids and enteral nutrition. Enteral nutrition is regarded as safe and is thought to contribute to clinical remission and mucosal healing.
Anti-TNF is used in moderate to severe disease that has failed to respond to conventional therapies. The REACH study established the efficacy of infliximab in paediatric Crohn's disease and led to its approval for this indication. Infliximab may enable corticosteroid dose tapering and improved growth.3
The 'step-up' approach to ulcerative colitis in children involves the initial use of aminosalicylates with progression to immunomodulators, surgery and anti-TNF therapy as needed. Corticosteroids can be effective initially, but long-term and steroid-free remission can be difficult to achieve.
The efficacy of infliximab therapy in the management of paediatric ulcerative colitis has been demonstrated in several studies4,5 with the response rate to infliximab found to be broadly similar to that observed in adults.
Long-term therapy and combination therapy
Relatively little information is available on long-term infliximab therapy in children with IBD. However, an open-label extension of the REACH reported sustained response and remission in initial responders, with 67% of patients remaining on infliximab therapy at 3 years.6
Children treated with infliximab have been found to require less corticosteroids and methotrexate. However, co-medication with thiopurines and other immunomodulators is common.
There is a risk of hepatosplenic T-cell lymphoma with the use of infliximab and concomitant immunosuppressants. In young males, the disease has been predominantly fatal.7 Clinical trial data and clinical registries have also confirmed that patients treated with anti-TNF therapy are at increased risk of infection. Healthcare professionals must therefore give focus to vaccinations and preventing infection. Guidelines for reducing risk of infection in adult patients can also be applied to children.
Transition to adult care
Transition from paediatric to adult care for teenagers with IBD should be a gradual and planned process between the ages of about 14 and 18.
"Transition between health services occurs at a time when there are many other changes for adolescents"
Transition also affects parents of patients, who may feel excluded after being involved with care of the child for many years. They may need prompting or assistance to 'step away'.
Excellent medical records and clear communication from the paediatric healthcare team can assist the adult team take on new patients. The paediatric team should be actively involved in the transfer process wherever possible, rather than simply referring their young patients to a new gastroenterologist.
10 steps for a successful transition to adult care:
- Identify a dedicated adult gastroenterologist and treatment team
- Tell the patient at about age 14 that transition 'starts now'
- Talk less to the parents and more to the child about the disease and its management
- Encourage discussion of 'adult' issues such as sex, drugs, school, work and cancer risk
- Teach teenagers about the disease and test their knowledge
- Send a report to the patient after each visit
- Let patients take responsibility for their own medications and prescriptions
- Check if the patient can tell when the disease worsens (some children try not to complain but they must learn when and how to seek help)
- Check if the patient can tell when treatment needs to be intensified
- Provide complete written information to the new doctor and the patient, as a comprehensive transition file
- Initial therapy for paediatric Crohn’s disease typically involves the use of immunomodulators alongside corticosteroids and enteral nutrition
- Infliximab has shown efficacy in the treatment of inflammatory bowel disease in paediatric patients
- Healthcare professionals should be aware of the risks of infliximab therapy and manage these risks
- Steps can be taken to ease the transition from paediatric care to adult care
Please note, the views expressed in this article are not necessarily those of the sponsor.
- Tung J et al. A population-based study of the frequency of corticosteroid resistance and dependence in pediatric patients with Crohn's disease and ulcerative colitis. Inflammatory Bowel Diseases 2006; 12: 1093–1100.
- Markowitz J et al. A multicenter trial of 6-mercaptopurine and prednisone in children with newly diagnosed Crohn's disease. Gastroenterology 2000; 119: 895–902.
- Hyams J et al. Induction and maintenance infliximab therapy for the treatment of moderate-to-severe Crohn's disease in children. Gastroenterology 2007; 132: 863–873.
- Turner D et al. Severe pediatric ulcerative colitis: a prospective multicenter study of outcomes and predictors of response. Gastroenterology 2010; 138: 2282–2291.
- Hyams et al. Randomized, multicenter, open-label phase 3 study to evaluate the safety and efficacy of infliximab in pediatric patients with moderate to severe ulcerative colitis. Gastroenterology 2011; 140: s124–s125.
- Hyams JS et al. Long-term outcome of maintenance infliximab therapy in children with Crohn's disease. Inflammatory Bowel Diseases 2009; 15:816–822.
- Remicade approved Product Information, 11 December 2013.
PBS information: This product is listed as a Section 100 item for Crohn’s disease and ulcerative colitis. Refer to PBS Schedule for full authority information.
Please refer to Product Information before prescribing. Full product Information is available here. Further information is available on request from Janssen-Cilag.
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