Skip Navigation
Skip to contents

Intest Res : Intestinal Research

IMPACT FACTOR

Articles

Page Path
HOME > Intest Res > Volume 18(2); 2020 > Article
Editorial Enteral nutrition in the biologic era: learn from yesterday, live for today, hope for tomorrow
Tadakazu Hisamatsu,orcid
Intestinal Research 2020;18(2):139-140.
DOI: https://doi.org/10.5217/ir.2019.09192
Published online: April 20, 2020

Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Mitaka, Japan

Correspondence to Tadakazu Hisamatsu, Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka 181-8611, Japan. Tel: +81-422-47-5511 (ext. 5729), Fax: +81-422-44-0655, E-mail: thisamatsu@ks.kyorin-u.ac.jp
• Received: December 30, 2019   • Accepted: January 3, 2020

© Copyright 2020. Korean Association for the Study of Intestinal Diseases. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

next
  • 5,708 Views
  • 134 Download
  • 4 Web of Science
  • 3 Crossref
  • 3 Scopus
See the article "Exclusive enteral nutrition for induction of remission in anti-tumor necrosis factor refractory adult Crohn’s disease: the Indian experience" on page 184.
See Article on [Related article:] 184
In the current issue of Intestinal Research, Sood et al. [1] reported the efficacy of exclusive enteral nutrition (EEN) for the induction of remission in adult patients with CD who were refractory to TNF inhibitors. Six patients who were refractory to TNF inhibitors received EEN for 12 weeks as a salvage therapy. Among them, 4 patients (66.6%) achieved clinical remission. In addition, improvement of perianal and entero-enteric fistulas was observed in some patients. EEN also improved BMI (from 15.6±3.1 to 18.9±1.9 kg/m2), hemoglobin levels (from 8.2±1.1 to 12.6±0.6 g/dL), and serum albumin levels (from 2.8±0.3 to 3.6±0.5 g/dL). All 6 patients were L3 (ileocolonic). Two of the 6 were B2 (stricturing) and the other 4 were B3 (penetrating). With TNF inhibitors becoming the mainstay of treatment for CD, managing primary nonresponders and patients that lose responsiveness to TNF inhibitors is an important issue. In this respect, the results of this study showing that EEN was effective in patients who were refractory to TNF inhibitors is significant.
There are several unsolved issues in this study. Most importantly, endoscopic assessment was not performed. EEN is presumed to be more effective for small bowel lesions than large bowel lesions. The difference in endoscopic improvement between small and large bowel lesions in ileocolonic type patients is of interest. This study sets clinical remission and fistula healing at week 12 as the primary endpoints. The subsequent clinical course of patients in whom EEN has shown efficacy should be followed. When considering the long-term management of CD, a few questions remain including: What is the appropriate maintenance therapy in patients who are in remission with EEN? Is continuous EEN over 12 weeks necessary? Is it necessary to switch to appropriate medication?
The efficacy of enteral nutrition (EN) for CD was first reported in 1974 by Bounous et al. [2] They reported 9 cases of “regional enteritis” who were treated with EN. Since then, its efficacy has mainly been reported in pediatric CD patients, and is still recommended [3]. On the other hand, evidence of EN for adult CD is not sufficient. The superiority of EN in comparison to pharmacotherapy in the induction of remission has not been proven, and there is some evidence for remission maintenance therapy [4,5].
A major problem with EN in adult patients with CD is poor adherence, because EN forces patients to restrict their diet. As large-scale, double-blind, placebo-controlled trials regarding EN are not realistic, high-quality evidence will continue to be difficult to generate. However, there are cases in adult CD patients who require EN in actual clinical practice such as patients with small intestinal or stenotic lesions. It is also true that EN is being re-evaluated in the biologics era as an adjuvant treatment [6]. Takagi et al. [7] reported that a half elementary diet was effective in preventing relapse in postoperative CD patients. Hirai et al. [8] reported the effectiveness of a combination therapy of EN with TNF inhibitors. In addition, concomitant use of EN with dose escalation of TNF inhibitors in patients with a loss of response has been investigated [9]. Thus, even in the biologics era, this editor believes that EN remains a viable treatment for CD especially since biologics are not as readily available in all countries. Its use is influenced by the approval status, insurance systems, and medical economics in each country. Also, in areas where the risk of infectious disease is high, concerns regarding biologics use are also relatively high, and EN remains a safe treatment option. In high endemic areas of intestinal tuberculosis and infectious enterocolitis, the use of biologics for the initial treatment may be hesitant.
Although the mechanism of action of EN in humans has not been fully elucidated, animal models have demonstrated that EN can influence epithelial barrier function, host metabolic status, and gut flora composition. There are reports of EN with various compositions, but the composition of EN that is most suitable for treating CD has not been determined. Considering the disease state, pharmacotherapy, including biologics, mainly have an inhibitory effect on inflammation and is not a fundamental treatment. With the role of the gut flora in IBD being particularly noted, the impact of EN on gut flora and metabolism may be worth reconsidering. From there, the best composition of EN and new therapeutic targets for CD can be discovered.
By re-reviewing EN, a historical treatment, this editor believes we can get clues for establishing new preventive medicine for IBD. “Learn from yesterday, live for today, hope for tomorrow”-Albert Einstein.

FINANCIAL SUPPORT

The author received no financial support for the research, authorship, and/or publication of this article.

CONFLICT OF INTEREST

No potential conflicts of interest relevant to this article were reported.

AUTHOR CONTRIBUTION

Writing and approval of final manuscript: Hisamatsu T.

  • 1. Sood A, Singh A, Sudhakar R, et al. Exclusive enteral nutrition for induction of remission in anti-tumor necrosis factor refractory adult Crohn’s disease: the Indian experience. Intest Res 2020;18:184–191.ArticlePubMedPMCPDF
  • 2. Bounous G, Devroede G, Haddad H, Beaudry R, Perey BJ, Lejeune LP. Use of an elemental diet for intestinal disorders and for the critically ill. Dis Colon Rectum 1974;17:157–165.ArticlePubMed
  • 3. Forbes A, Escher J, Hébuterne X, et al. ESPEN guideline: clinical nutrition in inflammatory bowel disease. Clin Nutr 2017;36:321–347.ArticlePubMed
  • 4. Narula N, Dhillon A, Zhang D, Sherlock ME, Tondeur M, Zachos M. Enteral nutritional therapy for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 2018;4–CD000542.Article
  • 5. Akobeng AK, Zhang D, Gordon M, MacDonald JK. Enteral nutrition for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev 2018;8–CD005984.Article
  • 6. Nguyen DL, Palmer LB, Nguyen ET, McClave SA, Martindale RG, Bechtold ML. Specialized enteral nutrition therapy in Crohn’s disease patients on maintenance infliximab therapy: a meta-analysis. Therap Adv Gastroenterol 2015;8:168–175.ArticlePubMedPMC
  • 7. Takagi S, Utsunomiya K, Kuriyama S, et al. Effectiveness of an ‘half elemental diet’ as maintenance therapy for Crohn’s disease: a randomized-controlled trial. Aliment Pharmacol Ther 2006;24:1333–1340.ArticlePubMed
  • 8. Hirai F, Ishihara H, Yada S, et al. Effectiveness of concomitant enteral nutrition therapy and infliximab for maintenance treatment of Crohn’s disease in adults. Dig Dis Sci 2013;58:1329–1334.ArticlePubMed
  • 9. Hisamatsu T, Kunisaki R, Nakamura S, et al. Effect of elemental diet combined with infliximab dose escalation in patients with Crohn’s disease with loss of response to infliximab: CERISIER trial. Intest Res 2018;16:494–498.ArticlePubMedPMCPDF

Figure & Data

REFERENCES

    Citations

    Citations to this article as recorded by  
    • Progress and Clinical Applications of Crohn’s Disease Exclusion Diet in Crohn’s Disease
      Duo Xu, Ziheng Peng, Yong Li, Qian Hou, Yu Peng, Xiaowei Liu
      Gut and Liver.2024; 18(3): 404.     CrossRef
    • Medical management of pediatric inflammatory bowel disease in the Asia‐Pacific region: A position paper by the Asian Pan‐Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group
      Way Seah Lee, Katsuhiro Arai, George Alex, Suporn Treepongkaruna, Kyung Mo Kim, Chee Liang Choong, Karen S. C. Mercado, Andy Darma, Anshu Srivastava, Marion M. Aw
      Journal of Gastroenterology and Hepatology.2023; 38(4): 523.     CrossRef
    • Clinical Features and Long-Term Outcomes of Paediatric-Onset Inflammatory Bowel Disease in a Population-Based Cohort in the Songpa-Kangdong District of Seoul, Korea
      Sang Hyoung Park, Jong Pil Im, Hyunju Park, Seung Kyu Jeong, Ji Hyun Lee, Kyoung Hoon Rhee, Young-Ho Kim, Sung Noh Hong, Kyung Ho Kim, Seung In Seo, Jae Myung Cha, Sun Yong Park, Joo Sung Kim, Hyuk Yoon, Sung Hoon Kim, Jisun Jang, Jeong Hwan Kim, Seong O
      Journal of Crohn's and Colitis.2022; 16(2): 207.     CrossRef

    • PubReader PubReader
    • ePub LinkePub Link
    • Cite
      CITE
      export Copy Download
      Close
      Download Citation
      Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

      Format:
      • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
      • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
      Include:
      • Citation for the content below
      Enteral nutrition in the biologic era: learn from yesterday, live for today, hope for tomorrow
      Intest Res. 2020;18(2):139-140.   Published online April 20, 2020
      Close
    • XML DownloadXML Download
    Enteral nutrition in the biologic era: learn from yesterday, live for today, hope for tomorrow
    Enteral nutrition in the biologic era: learn from yesterday, live for today, hope for tomorrow

    Intest Res : Intestinal Research
    Close layer
    TOP