Intervention Review

Enteral nutritional therapy for induction of remission in Crohn's disease

  1. Mary Zachos*,
  2. Melody Tondeur,
  3. Anne Marie Griffiths

Editorial Group: Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group

Published Online: 24 JAN 2007

Assessed as up-to-date: 2 OCT 2006

DOI: 10.1002/14651858.CD000542.pub2


How to Cite

Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD000542. DOI: 10.1002/14651858.CD000542.pub2.

Author Information

  1. The Hospital for Sick Children, Division of Gastroenterology, Hepatology & Nutrition, Toronto, Ontario, Canada

*Mary Zachos, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. mary.zachos@sickkids.ca.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 24 JAN 2007

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要

Background

The role of enteral nutrition in Crohn's disease is controversial. Increasing research on the mechanisms by which nutritional therapy improves the clinical well being of patients with Crohn's disease has led to novel formula design and trials comparing two different forms of enteral nutrition. This meta-analysis aims to provide an update on the existing effectiveness data for both corticosteroids versus enteral nutrition and for one form of enteral nutrition versus another for inducing remission of active Crohn's disease.

Objectives

To evaluate the effectiveness of exclusive enteral nutrition (EN) as primary therapy to induce remission in Crohn's disease and to examine the importance of formula composition on effectiveness.

Search methods

Studies were selected using a computer-assisted search of the on-line bibliographic databases MEDLINE (1966-2006) and EMBASE (1984-2006), as well as the Science Citation Index on Web of Science. Additional citations were sought by manual search of references of articles retrieved from the computerized search, abstracts submitted to major gastroenterologic meetings and published in the journals: American Journal of Gastroenterology, Gut, Gastroenterology, Journal of Pediatric Gastroenterology and Nutrition, and Journal of Parenteral and Enteral Nutrition, and from the reviewers' personal files or contact with leaders in the field.

Selection criteria

All randomized and quasi-randomized controlled trials involving patients with active Crohn's disease defined by a clinical disease activity index were considered for review. Studies evaluating the administration of one type of enteral nutrition to one group of patients and another type of enteral nutrition or conventional corticosteroids to the other group were selected for review.

Data collection and analysis

Data were extracted independently by two authors and any discrepancies were resolved by rereading and discussion. For the dichotomous variable, achievement of remission, individual and pooled trial statistics were calculated as odds ratios (OR) with 95% confidence intervals (CI); both fixed and random effect models were used. The results for each analysis were tested for heterogeneity using the chi square statistic. The studies were separated into two groups: A. one form of enteral nutrition compared with another form of enteral nutrition and B. one form of enteral nutrition compared with corticosteroids. Subgroup analyses were conducted on the basis of clinical or disease criteria and formula composition. Sensitivity analyses were conducted on the basis of the inclusion of abstract publications, methodologic quality and by random or fixed effects models.

Main results

In part A, of the 15 included eligible trials (one abstract) comparing different formulations of EN for the treatment of active CD, 11 compared one (or more) elemental formula to a non-elemental one, three compared enteral diets of similar protein composition but different fat composition, and one compared non-elemental diets differing only in glutamine enrichment. Meta-analysis of ten trials comprising 334 patients demonstrated no difference in the efficacy of elemental versus non-elemental formulas (OR 1.10; 95% CI 0.69 to 1.75). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no statistically significant differences. Further analysis of seven trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no statistically significant difference in efficacy (OR 1.13; 95% CI 0.63 to 2.01). Similarly, the effect of very low fat content (< 3 g/1000 kCal) or type of fat (long chain triglycerides) were investigated, but did not demonstrate a difference in efficacy in the treatment of active CD, although a non significant trend was demonstrated favoring very low fat and very low long chain triglyceride content. This result should be interpreted with caution due to statistically significant heterogeneity and small sample size. Sensitivity analyses had no significant effects on the results. The role of specific fatty acids or disease characteristics on response to therapy could not be evaluated. In part B, eight trials (including two abstracts) comparing enteral nutrition to steroid therapy met the inclusion criteria for review. Meta-analysis of six trials that included 192 patients treated with enteral nutrition and 160 treated with steroids yielded a pooled OR of 0.33 favouring steroid therapy (95% CI 0.21 to 0.53). A sensitivity analysis including the abstracts resulted in an increase in the number of participants to 212 in the enteral nutrition group and 179 in the steroid group but the meta-analysis yielded a similar result (OR 0.36; 95% CI 0.23 to 0.56). There were inadequate data from full publications to perform further subgroup analyses by age, disease duration and disease location.

Authors' conclusions

Corticosteroid therapy is more effective than enteral nutrition for inducing remission of active Crohn's disease as was found in previous systematic reviews. Protein composition does not influence the effectiveness of EN in the treatment of active CD. A non significant trend favouring very low fat and/or very low long chain triglyceride content exists but larger trials are required to explore the significance of this finding.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要

Enteral nutritional therapy for treatment of active Crohn's disease

Evidence continues to indicate that corticosteroids are more effective than enteral nutrition (liquid food) for treating active Crohn's disease. Comparing one form of enteral nutrition to another has not shown any difference in effectiveness for treating active Crohn's disease, but a non significant trend favouring low fat formulations has emerged. Further research is required.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要

利用腸道營養治療緩解克隆氏症

研究背景

腸道營養對於克隆氏症的功效目前還是有爭議的。由於有越來越多關於營養治療對於克隆氏症患者臨床改善機制的研究, 因此出現了新穎的配方設計,並且有研究比較兩種不同的腸道營養形式。本統合分析主要希望能夠提供對於類固醇治療和腸道營養治療,以及兩種不同形式腸道營養治療,對於緩解活性克隆氏症效果的更新數據。

研究目的

評估單獨以腸道營養作為緩解克隆氏症的主要治療方法的效益,並且評估配方成分對於效果的重要性。

检索方法

利用電腦輔助搜尋線上書目型資料庫 MEDLINE (1966年–2006年)以及EMBASE (1984–2006年),還有Science Citation Index on Web of Science以挑選出研究。此外並以人工的方式,搜尋從:電腦搜尋、主要腸胃道研討會摘要、期刊刊物:American Journal of Gastroenterology、Gut、 Gastroenterology、Journal of Pediatric Gastroenterology and Nutrition、 Journal of Parenteral and Enteral Nutrition以及所獲文章的參考文獻。

纳入标准

根據符合臨床疾病活性指標所定義的活性克隆氏症患者進行的所有隨機和半隨機對照試驗都會被列入本文獻回顧。研究會挑選出一組接受一種類型腸道營養的病患,與另一組接受另一種腸道營養或傳統性類固醇治療的病患以在本文獻回顧中進行比較。

数据收集与分析

兩名作者會獨立摘錄數據,意見不一致的部分會藉由重新閱讀和討論來解決。對於二元性變異、達到緩解、個別或群體試驗統計結果都以95%CI內的OR值來表示。文獻回顧中會使用固定效應和隨機效應模式。每一個分析的結果都會利用卡方統計檢驗試驗異質性,這些研究也會被分為兩個組別,A組是將兩種不同形式腸道營養進行比較,B組是將某類形的腸道營養與糖皮質類固醇進行比較,次組別分析是根據臨床或疾病的標準以及成分配方來進行,敏感度分析則是根據納入文獻回顧的公開摘要、方法學品質並利用隨機或固定效應模式進行計算。

主要结果

在A部分,有15個可納入的試驗(一篇是摘要),這些試驗是比較使用不同配方的腸道營養來治療活性克隆氏症,其中有11個研究(或是更多)是將元素配方和非元素配方進行一對一比較,3個研究是比較具有相近蛋白質成分但是具有不同脂肪成分的腸道飲食,而另一個研究則是比較不同的非元素飲食,其中各組的差別僅在於麩醯胺酸的含量。對於包括334病患的10個試驗進行統合分析可以證實使用元素或非元素配方的組別在功效上並沒有差異(OR值為1.10,95%CI介於0.69至1.75間),次組別分析的結果顯示對於不同類別的元素和非元素(元素、半要素和聚合)飲食進行評估,顯示並沒有統計上顯著差異;針對包含209名病患的7個試驗進行進一步的分析顯示,使用具有不同脂肪含量(低脂肪:每1000大卡熱量小於20克脂肪,高脂肪:每1000大卡熱量大於20克脂肪)的腸道配方,並沒有在功效上產生統計學上的明顯差異(OR值為1.13,95%CI介於0.63至2.01間),十分相似的,也針對非常低脂肪含量(每1000大卡熱量小於3克脂肪)或是不同類型的脂肪(長鏈三酸甘油脂)進行研究,但是也無法證明對於活性克隆氏症的治療會產生不同效果,雖然使用非常低含量的脂肪或是長鏈三酸甘油脂對於緩解克隆氏症顯示有效的趨勢但卻無統計上顯著的差異,因為研究結果具有統計上顯著異質性,且研究規模較小,所以這個研究應該要被謹慎解釋。 敏感度分析也沒有對結果產生明顯影響,且無法對特定脂肪酸的角色或是對治療產生反應的疾病特徵進行評估。在B部分中,本文獻回顧納入了8個比較腸道營養和類固醇治療效果的試驗(包含兩篇摘要),針對6個試驗進行的統合分析中,有 192名患者使用腸道營養治療,160名患者使用類固醇,其中總合勝率比為0.33,且結果傾向於類固醇治療(95%CI介於0.21至0.53間),針對包括摘要在內進行的敏感度分析中使用腸道營養治療的患者人數增加至212人,使用類固醇的患者人數則增加至179人,但是統合分析結果仍十分相近(OR值為0.36,95%CI介於0.23至0.56間),從公開發表的全文中因無足夠的數據,故無法進一步依年齡、患病期間和患病部位完成次組別分析。

作者结论

在之前的系統性文獻回顧中可以發現糖皮質類固醇治療比腸道營養更能夠緩解活性克隆氏症,蛋白質成分並不會影響腸道營養療法對於活性克隆氏的治療效果,有一個不明顯的趨勢傾向於使用非常低含量的脂肪或是長鏈三酸甘油脂,但是仍需要進行大型試驗來探討這個發現的顯著性。

 

概要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要

利用腸道營養治療緩解克隆氏症

糖皮質類固醇治療比腸道營養更能夠治療活性克隆氏症。證據持續指出糖皮質類固醇治療比腸道營養(液體餵食)更能夠治療活性克隆氏症,將不同形式的腸道營養進行比較並沒有發現不同型式的腸道營養對於活性克隆氏症的治療效果上會產生明顯差異,但是有一些不明顯的趨勢則傾向於使用非常低含量脂肪配方的腸道營養,也需要進行更進一步的研究。

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