Enteral nutrition for the maintenance of remission in Crohnʼs disease: a systematic review

Yamamoto, Takayuki; Nakahigashi, Maki; Umegae, Satoru; Matsumoto, Koichí

doi:10.1097/meg.0b013e32832c788c

Cited by 66 publications

(47 citation statements)

References 31 publications

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“…28 For example, in Japan, enteral nutrition is recommended as the first-line treatment in the management of active CD. 31,35 It has also been recommended by the European Society of Parenteral and Enteral Nutrition as first-line therapy in children and young adults with concerns about growth and side effects if corticosteroid therapy is not appropriate. 36 Although enteral nutrition has been shown to be an effective and safe intervention for induction of remission in patients with active CD, withdrawal from enteral nutrition and resumption of normal diet would often be followed by recurrence of gastrointestinal symptoms and use of corticosteroids.…”

Section: Enteral Nutrition As Induction Therapymentioning

confidence: 99%

“…1,3,4,15 Specifically, only two systematic reviews evaluated effectiveness of elemental nutrition in maintaining remission for patients with CD. 30,35 The Cochrane review, published in 2009, included only two randomised controlled trials (RCTs). 30 The other review by Yamamoto et al 35 published in 2010 included one RCT, three non-randomised controlled trials (nRCTs) and six retrospective cohort studies.…”

Section: Enteral Nutrition As Maintenance Therapymentioning

confidence: 99%

“…30,35 The Cochrane review, published in 2009, included only two randomised controlled trials (RCTs). 30 The other review by Yamamoto et al 35 published in 2010 included one RCT, three non-randomised controlled trials (nRCTs) and six retrospective cohort studies. This review did not provide formal assessment of methodological quality of individual studies.…”

Section: Enteral Nutrition As Maintenance Therapymentioning

confidence: 99%

“…29,35 There is less clarity of the role of enteral nutrition in maintaining remission in patients with quiescent CD. The available evidence is insufficient or inconclusive and needs to be updated.…”

Section: Decision Problemmentioning

confidence: 99%

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Clinical effectiveness and cost-effectiveness of elemental nutrition for the maintenance of remission in Crohn’s disease: a systematic review and meta-analysis

Tsertsvadze

Gurung

Court

et al. 2015

Health Technology Assessment

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BackgroundAlthough enteral nutrition has been shown to be a viable treatment option for the management of active Crohn’s disease (CD), the evidence regarding its clinical benefits compared with standard treatments (e.g. steroids) for maintaining remission in patients with CD has been inconsistent. If enteral nutrition was to be effective, the use of drugs such as steroids and immunosuppressive drugs could be reduced, thereby reducing the likelihood of adverse events associated with these medications.ObjectivesThis systematic review aimed to assess the clinical effectiveness and cost-effectiveness of elemental nutrition (a type of enteral nutrition) for maintenance of remission in patients with CD.Data sourcesMajor bibliographic databases (e.g. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews) were searched from inception to August/September 2013. Searches were not limited by study design, language or publication date. Websites for relevant organisations and references of included studies were checked.MethodsExperimental randomised and non-randomised controlled trials (RCTs and nRCTs) reporting clinical effectiveness and cost-effectiveness of elemental nutrition in the maintenance of remission in patients with CD were eligible. Study selection, data extraction and risk of bias (RoB) assessment were performed independently. Risk ratios (RRs) and mean differences (MDs) were pooled using a random-effects model. Heterogeneity was assessed via forest plots, Cochran’sQand theI2statistics. Overall, quality of evidence for each outcome was rated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.ResultsEight studies (three RCTs and five nRCTs) were included in the review. RCTs indicated a significant benefit of elemental nutrition vs. no intervention (an unrestricted diet) in maintaining remission at 24 months [one RCT; RR 2.06, 95% confidence interval (CI) 1.00 to 4.43; very low-grade evidence] and preventing relapse at 12–24 months post baseline (two RCTs; pooled RR 0.57, 95% CI 0.38 to 0.84;I2 = 0%; high-grade evidence). Similarly, three nRCTs showed significant benefits of elemental nutrition over no intervention in maintaining remission at 12–48 months and preventing relapse at 12 months post baseline (MD 1.20 months, 95% CI 0.35 to 2.04 months). The incidence of mucosal healing was not significantly different in the intervention and control groups (RR 2.70, 95% CI 0.62 to 11.72). Adherence to an elemental nutrition regime was significantly worse than adherence to polymeric nutrition (RR 0.68, 95% CI 0.50 to 0.92) and, when compared with other active treatments (medications, polymeric nutrition or a combination), elemental nutrition yielded non-significant results with wide 95% CIs, rendering these results inconclusive. Complications and adverse events were too sparse to allow meaningful comparisons. None of the studies reported cost-effectiveness of elemental nutrition. Owing to scarcity of data, subgroup and sensitivity analyses could not be performed to explore methodological and clinical sources of heterogeneity.LimitationsThe findings warrant cautious interpretation given the limitations of the evidence in methodological quality (small samples, short follow-up) and the RoB in individual studies (lack of blinding, confounding).ConclusionsLimited evidence indicates potential benefits of elemental nutrition against no intervention in the maintenance of remission and prevention of relapse in adult patients with CD. There was a lack or insufficient evidence on adverse events and complications. Future large and long-term randomised trials are warranted to draw more definitive conclusions regarding the effects of elemental nutrition in maintaining remission in CD.Trial registrationThis study is registered as PROSPERO CRD42013005134.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Enteral Nutrition As Induction Therapymentioning

confidence: 99%

Section: Enteral Nutrition As Maintenance Therapymentioning

confidence: 99%

Section: Enteral Nutrition As Maintenance Therapymentioning

confidence: 99%

Section: Decision Problemmentioning

confidence: 99%

See 2 more Smart Citations

Clinical effectiveness and cost-effectiveness of elemental nutrition for the maintenance of remission in Crohn’s disease: a systematic review and meta-analysis

Tsertsvadze

Gurung

Court

et al. 2015

Health Technology Assessment

View full text Add to dashboard Cite

show abstract

“…In one non-randomized trial, the relapse rate at 1 year was 25 % in the EN group versus 65 % in the non-EN group, with reported significant improvement in average endoscopy scores, with decreased mucosal concentrations of IL-1b, -6, and TNF [9]. In a meta-analysis of seven studies, EN with elemental, semi-elemental or polymeric diets orally or via tube feeds had higher clinical remission rates compared to groups ingesting ordinary foods [12].…”

mentioning

confidence: 97%