RAMB - Dezembro

lara

APHS

898

ssoc

ras

2016; 62(9):895-900

al.

the

odds ratio

for clinical response to budesonide com-

pared to a placebo was 12.32 (95CI 5.53-27.46), with an

81% response rate.

The same efficacy of budesonide at the dose of 9 mg/

day has been demonstrated in the treatment of LC by two

placebo-controlled studies conducted in 2009 by Miehl-

ke et al.

and Pardi et al.

Both studies also showed sub-

stantial improvement in colon inflammation.

21,22

Two

other randomized placebo-controlled trials conducted

by Bonderup et al.

and Miehlke et al.

showed that clin-

ical remission and histological response could be main-

tained in most patients with budesonide at a dose of 6

mg/day for 6 months, with an 83% response rate.

After stopping treatment with budesonide, relapse of

symptoms may occur in 60 to 80% of patients, most of

which respond to retreatment.

1,5,7,9,25

Many patients there-

fore become steroid-dependent. As such, before starting

budesonide, the diagnosis should be reviewed and differ-

ential diagnoses ruled out, such as celiac disease and hy-

perthyroidism.

1,2

Patients treated with long-term budesonide should

be monitored for side effects associated with the use of

steroids, such as hypertension, hyperglycemia and chang-

es in bone metabolism, among other factors. Further-

more, they should avoid consuming grapes, grape juice

and any other cytochrome P450 inhibitors that interfere

with the metabolism of budesonide and predispose to

side effects.

The main advantage of budesonide in relation to con-

ventional corticosteroids is its limited systemic absorp-

tion, which leads to better long-term tolerance.

Further-

more, it presents fewer side effects than prednisone, with

higher efficacy demonstrated in 2013 by Gentile et al.

in an uncontrolled study. Therefore, unless cost is a ma-

jor concern, budesonide is generally used when cortico-

therapy is required.

Prednisolone has been analyzed in retrospective stud-

ies conducted by Olesen et al.,

Bohr et al.

and Pardi et

al.

and in a randomized placebo-controlled trial carried

out by Munck et al.

In the comparison, patients using

budesonide showed lower recurrence than those treated

with prednisolone. Therefore, prednisolone does not ap-

pear to be of value in the treatment of patients who do

not respond to budesonide.

Sulfasalazine or mesalazine have been widely used in

MC, but have not been strictly evaluated in randomized

placebo-controlled trials.

In the treatment of MC, me-

salazine has mainly been reported in retrospective stud-

ies carried out in 1996 by Bohr et al.

and in 2004 by Ole-

sen et al.,

suggesting a therapeutic response in about

half of patients. In 2008, Chande et al.

conducted an

uncontrolled prospective study that showed greater effi-

cacy of mesalazine when administered over a period of 6

months. Due to the lack of control groups, the true val-

ue of the use of mesalazine when treating MC remains

inconclusive.

7,32

Calabrese et al.

conducted a randomized study with

23 patients with CC and 41 with LC who received 2.4 g/

day of mesalazine monotherapy, or in combination with

4 g/day of cholestyramine for 6 months. Disease remis-

sion was noted in 91% of the patients with CC and 85%

of the patients with LC after 6 months of treatment. Com-

bined therapy presented the best responses.

Immunosuppressive therapies, such as azathioprine,

6-mercaptopurine or methotrexate, may be useful in ste-

roid-dependent or steroid-refractory patients.

1,5,7-9,14

There are only a few reports of the use of anti-TNF

(tumor necrosis factor inhibitors) agents in patients with

CC at similar doses to those for IBD. However, a risk-ben-

efit analysis should be completed, and regular monitor-

ing is necessary.

Probiotics

Lactobacillus acidophilus

LA-5 and

Bifidobac-

terium animalis

subsp.

lactis

BB12 (AB-Cap-10) did not

show any benefit over the placebo with regard to clinical

response, histological improvement or quality of life when

administered for 12 weeks.

Pentoxifylline, verapamil and subcutaneous octreo-

tide could be treatment options, but their use has not yet

been recommended.

Metronidazole and erythromycin

may be beneficial in some patients, although diarrhea

may occur again when the medication is withdrawn.

2,9

Surgical intervention in patients with MC should be

considered as a last resort in cases refractory to all inter-

ventions. Ileostomy with or without colectomy or ileal

pouch-anal anastomosis have been successfully performed

in some cases.

1,2,5,7-9

rognosis

The natural history of MC is benign and variable, with

many self-limited cases. However, patients can be severe-

ly affected. It is possible to have periods of spontaneous

remission and relapse, as well as an ongoing pattern.

Some cases of MC have been reported as progressing

into Crohn’s disease or ulcerative colitis, but there are still

no studies to demonstrate such involvement.

The risk of

cancer and mortality is similar to that of the population.

The long-term prognosis of MC is generally good. In

a follow-up study on CC conducted by Goff et al.,

63%

of patients remained in remission after 3.5 years. Mean-

while, in another cohort study conducted by Bonner et