The following is an overview of a presentation by Professor Michael Kamm from St Vincent's Hospital, Melbourne, at the Raising Expectations in Gastroenterology symposium, 2011.

Current treatment options allow almost every patient with chronic active colitis to achieve remission. In the presence of chronic active disease or frequent recurrences, the first step is to check that the patient has undergone an adequate trial of oral and topical 5-aminosalicylic acid (5-ASA) and patient compliance to therapy. Standard second-line therapy for these patients is azathioprine or mercaptopurine, but tacrolimus is favoured by some specialists. Optimising the use of thiopurines can offer advantages to many patients. Other options in treatment-resistant cases include apheresis, probiotics, appendectomy, the anti-inflammatory herb turmeric, and faecal transplantation, but their precise roles are yet to be defined.

Anti-TNF therapy

Anti-TNF therapy is now an established option for resistant disease. The ACT-1 and ACT-2 studies established that, in patients with moderate to severe ulcerative colitis despite existing medication, infliximab can improve the clinical response compared to placebo. In ACT-1, 45% of patients treated with infliximab were in clinical remission at week 54 compared to 20% treated with placebo (p=0.001).1 In the ACT-1 and -2 extension studies, between 90% and 94% of patients treated with open-label infliximab every 8 weeks had no or mild disease at week 152.2

The long-term benefits of anti-TNF therapy can be attained in routine clinical practice as well as in clinical trials.

"If you achieve remission with infliximab, then your chance of staying in remission on this therapy is very good"

Combination therapy of infliximab and azathioprine is becoming increasingly common. In the SUCCESS study, treatment with the combination of the two agents was significantly superior to monotherapy with either agent when assessed by steroid-free remission at week 16 (p=0.032 vs azathioprine, p=0.017 vs infliximab).3

Strategies for treating pouchitis

  Suggested treatment
New-onset acute pouchitis Metronidazole for 2 weeks
Resistant or recurrent pouchitis Ciprofloxacin-metronidazole combination
Pre-pouch ileitis Ciprofloxacin-metronidazole combination
Chronic pouchitis Maintenance antibiotics Immunomodulators may also be required

It has been suggested that probiotics may be effective in maintaining remission.

Novel approaches to refractory ulcerative colitis management

  • Appendectomy, in the absence of appendicitis4

     

    • Investigated in a prospective study of 30 patients
    • Shown to reduce the median Simple Clinical Colitis Activity Index score from 9 to 2, and improve the score for 90% of patients
    • Encouraged complete symptom resolution in one year for 40% of patients
  • Faecal flora transplant5

     

    • Proven to be a 'promising' approach by pilot studies, with remission for up to 13 years has been reported

Summary

  • Current treatment options allow almost every patient with chronic active colitis to achieve remission
  • Anti-TNF therapy is now an established option for resistant disease
  • Combination therapy of infliximab and azathioprine is becoming increasingly common
  • Medical management of pouchitis may involve antibiotic and immunomodulator use

Please note, the views expressed in this article are not necessarily those of the sponsor.

References

  1. Rutgeerts P et al. Infliximab for induction and maintenance therapy for ulcerative colitis. New England Journal of Medicine 2005; 353: 2462–2476.
  2. Reinisch W et al. Long-term infliximab maintenance therapy for ulcerative colitis: the ACT-1 and -2 extension studies. Inflammatory Bowel Diseases 2012; 18: 201–211.
  3. Panaccione et al. Presented at DDW 2011. Abstract 835.
  4. Bolin TD et al. Appendicectomy as a therapy for ulcerative proctitis. American Journal of Gastroenterology 2009; 104: 2476–2482.
  5. Borody TJ et al. Treatment of ulcerative colitis using fecal bacteriotherapy. Journal of Clinical Gastroenterology 2003; 37: 42–47.

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.

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