Enteral nutrition for maintenance of remission in Crohn's disease

Abstract

Prevention of relapse is a major issue in the management of Crohn's disease. Corticosteroids and 5-ASA preparations are not effective for the maintenance of remission. Methotrexate, infliximab, 6-mercaptopurine and its prodrug, azathioprine may be effective in maintaining remission, but these drugs may cause significant adverse events. To conduct a systematic review to evaluate the efficacy of enteral nutrition for the maintenance of remission in Crohn's disease. MEDLINE (1966 to January 2007), EMBASE (1984 to January 2007) the Cochrane Central Register of Controlled Trials from the Cochrane Library (Issue 4, 2006) and the IBD/FBD Review Group Specialized Trials Register were searched. The articles cited in each publication were hand searched. Randomised controlled trials which compared enteral nutrition with no intervention, placebo or with any other intervention were eligible for inclusion. Data extraction and assessment of methodological quality of included studies were independently performed by two authors. The main outcome measure was the occurrence of clinical or endoscopic relapse as defined by the primary studies. Odds ratios and 95% confidence intervals were calculated for dichotomous outcomes. Two studies were identified that met the inclusion criteria and were included in the review. Statistical pooling of the results of these studies was not possible because the control interventions, and the way outcomes were assessed differed greatly between the two studies. In one study (Takagi 2006), patients who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a significantly lower relapse rate compared to patients who received unrestricted normal diet (9 of 26 versus 16 of 25; OR 0.3, 95% CI 0.09 to 0.94). In the other study (Verma 2001), elemental and polymeric feeds (providing between 35 and 50% of patients' pretrial calorie intake in addition to unrestricted normal food) were equally effective for maintenance of remission and allowing withdrawal of steroid therapy (8 of 19 versus 6 of 14; OR 0.97, 95% CI 0.24 to 3.92). The available evidence suggests that supplementary enteral nutritional may be effective for maintenance of remission in Crohn's disease. Whilst larger studies are needed to confirm these findings, enteral nutritional supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in Crohn's disease.