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Utah Gastroenterology

Happy New Year to all our readers and friends.
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Low-Dose Budesonide for Maintenance of Clinical Remission in Collagenous Colitis

This study compared outcomes with a primary endpoint of clinical remission for patients randomized to receive 4.5 mg/day budesonide or placebo for active collagenous colitis. At 1 year, 61.4% of budesonide patients were in remission compared with 16.7% of the control group. No serious adverse reactions were reported. Following discontinuation of budesonide, 82.1% of patients who had previously received budesonide experienced relapse.

Based on these results, budesonide is safe and effective to maintain clinical remission for at least 1 year. Longer treatment may be needed as relapse is common after discontinuation of treatment.

Microscopic colitis (lymphocytic, collagenous colitis) is recognized as a common inflammatory bowel disease, especially in the elderly population. The often chronic, watery diarrhea leads to urgency and fecal incontinence. According to European recommendations budesonide should be given as first-line therapy. Approximately up to 80% of patients experience a clinical relapse after cessation of budesonide treatment.

This 1-year study aimed to assess low-dose budesonide therapy for maintenance of clinical remission in patients with collagenous colitis.

DESIGN: A prospective, randomised, placebo-controlled study beginning with an 8-week open-label induction phase in which patients with histologically confirmed active collagenous colitis received budesonide (Budenofalk, 9 mg/day initially, tapered to 4.5 mg/day), after which 92 patients in clinical remission were randomised to budesonide (mean dose 4.5 mg/day; Budenofalk 3 mg capsules, two or one capsule on alternate days) or placebo in a 12-month double-blind phase with 6 months treatment-free follow-up. Primary endpoint was clinical remission throughout the double-blind phase.

RESULTS: Clinical remission during open-label treatment was achieved by 84.5% (93/110 patients). The median time to remission was 10.5 days (95% CI (9.0 to 14.0 days)). The maintenance of clinical remission at 1 year was achieved by 61.4% (27/44 patients) in the budesonide group versus 16.7% (8/48 patients) receiving placebo (treatment difference 44.5% in favour of budesonide; 95% CI (26.9% to 62.7%), p<0.001). Health-related quality of life was maintained during the 12-month double-blind phase in budesonide-treated patients. During treatment-free follow-up, 82.1% (23/28 patients) formerly receiving budesonide relapsed after study drug discontinuation. Low-dose budesonide over 1 year resulted in few suspected adverse drug reactions (7/44 patients), all non-serious.

CONCLUSIONS: Budesonide at a mean dose of 4.5 mg/day maintained clinical remission for at least 1 year in the majority of patients with collagenous colitis and preserved health-related quality of life without safety concerns. Treatment extension with low-dose budesonide beyond 1 year may be beneficial given the high relapse rate after budesonide discontinuation.
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Antimicrobial Effects of Rifaximin on Gut Microbiota

This review evaluated the mechanism of action of rifaximin causing efficacy in the treatment of travelers’ diarrhea (TD). While rifaximin is known to be a broad-spectrum, bactericidal antibiotic, it is effective in TD without eradication of the causal bacteria and with little effect on the normal gut flora. This suggests alternative mechanisms of action. Preclinical studies suggest that rifaximin may have effects on both the bacteria and the host. Host effects include inhibiting bacterial attachment and reducing mucosal inflammation.

Disruption of the gut microbiota through use of systemic antimicrobials or activation of the mucosal inflammatory response by pathogens can cause dysregulation of the intestinal mucosa.

AIM: To explore the mechanisms of action of rifaximin that may underlie its clinical benefits in travellers' diarrhoea (TD).

METHODS: A literature search was performed using the terms 'rifaximin' and 'L/105' in combination with the terms 'in vitro activity', 'diarrhea', 'microbiota' and 'gut flora'.

RESULTS: Rifaximin has been traditionally identified as a nonsystemic, broad-spectrum, bactericidal antibiotic. Evidence shows that the activity of rifaximin against enteropathogens in this setting is likely enhanced by its increased solubility in the presence of bile acids in the small intestine. Results of clinical studies show that although rifaximin is efficacious in TD, a clinical cure often occurs without apparent bacterial eradication and with minimal effect on the gut microbiota, suggesting an effect of rifaximin other than direct antibiotic activity.

CONCLUSIONS: Although definitive studies on the effect of rifaximin on the gut microbiota in large cohorts of healthy volunteers or patients have not been published, pre-clinical studies provide some insight. These studies have shown that rifaximin may have effects on both the pathogen and host, including direct effects on pathogenic bacteria (such as reducing the expression of bacterial virulence factors) and indirect effects on the host (such as inhibiting bacterial attachment and internalisation at the intestinal mucosa and reducing mucosal inflammation).
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A Must-Read For Every Healthcare Provider: Physicians Discuss Empathy, Stronger Connections With Patients.

The Washington Post reports on specific ways doctors can make a connection so that patients feel understood, as outlined in an new essay in the Journal of the American Medical Association: The stronger the physician-patient connection, the more likely patients are to take their medicine or otherwise work with their doctors, resulting in improved health. Physicians need to be authentic, emotionally available and engaged, recognize their patient’s suffering, and treat them as whole persons, not just diseases. Being engaged like this also helps physicians reconnect with a deeper purpose in their work.
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Study finds link between IBS, vitamin D levels 
A study found 82% of patients with irritable bowel syndrome were vitamin D deficient. Patients given vitamin D supplements, with and without probiotics, had increased vitamin D levels and improvements in IBS symptoms, compared with those given a placebo. 
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Researchers call for more data on long-term efficacy of fecal transplants

A review and meta-analysis found that more data is needed to determine the long-term efficacy and safety of fecal microbiota transplantation for recurrent Clostridium difficile infection. Researchers found a primary cure rate of 91.2%, with higher cure rates with transplants via lower, rather than upper, gastrointestinal route. The study team said the available evidence was limited, and more data is needed from randomized, controlled trials.
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Merry Christmas and Happy Holidays

As the holidays and the end of the year are upon us, everyone at Utah Gastroenterology would like to thank our friends and patients, who trust UG with their healthcare needs, for a great and exciting year 2015.
We hope you have a wonderful Holiday Season, Christmas and New Year.
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Stopping or Switching TNF Worsens IBD:

Disease flares were tripled in the year after changing treatment

Patients whose inflammatory bowel disease was managed with a tumor necrosis factor inhibitor but whose treatment was changed for reasons other than safety or efficacy typically had worse outcomes than those who continued with the successful treatment, as presented in a poster session at the Advances in Inflammatory Bowel Diseases meeting 2015.

Advances in Inflammatory Bowel Diseases
Wolf D, et al "Clinical outcomes associated with non-medical switching or discontinuation of anti-TNF inhibitors among patients with inflammatory bowel disease" AIBD 2015; Abstract P20.
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Study assesses familial risk for celiac disease 

Sisters are the most likely relatives of people with celiac disease to also have the disease. Daughters were the next most likely, followed by sons, brothers, mothers and fathers, as reported in The American Journal of Gastroenterology. First-degree relatives in the US were more likely than first-degree relatives in Europe, South America or Asia to have celiac disease.
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