AIBD 2010: Lessons Learned in the Treatment of Pediatric and Adult IBD

Lessons learned in the management of children with inflammatory bowel disease (IBD) may help gastroenterologists improve the diagnosis and management of adults with the condition, according to research presented at the 2010 Advances in Inflammatory Bowel Diseases, the Crohn’s & Colitis Foundation’s Clinical & Research Conference, being held December 9-12 in Hollywood, Florida.

Overall, the number of cases of pediatric IBD is increasing, with approximately 50,000 US children under age 18 having either ulcerative colitis (UC) or Crohn’s disease (CD). Up to 25% of IBD cases first present in childhood. During a clinical session focusing on state-of-the-art management of IBD, Athos Bousvaros, MD, MPH, associate professor of pediatrics at Harvard Medical School and associate director of the Inflammatory Bowel Disease Program at Children's Hospital Boston, discusses key issues in IBD and immune deficiency, treatment of UC and CD in children, and special considerations in the management of children including growth, immunizations, and depression.

In very young children, primary immunodeficiency -- including chronic granulomatous disease, Wiskott-Aldrich syndrome, and common variable immune deficiency -- can cause IBD. Bousvaros said that clinicians should “Consider primary immune deficiency syndromes in patients with a history of recurrent infections (especially pneumonia), syndromic children and adults, and children with other autoimmune manifestations, including hemolytic anemia, eczema, autoimmune enteropathy, and high IGE levels. Diagnosis is essential, as therapy for many of these conditions involves stem cell transplant rather than immune suppression.” He also reminded the audience that pediatric IBD patients may present with different phenotypic characteristics as compared to adults.

Treatment goals in adolescents with IBD are similar to treatment goals for their adult counterparts; however, management may require a slightly different approach. In treating adolescent patients, physicians should aim for clinical remission, not just clinical response; avoid overusing corticosteroids when immunosupression may be needed; and avoid overusing immunosupression when surgery may be needed. In addition, adolescents should be monitored closely for disease progression and treatment effects as well as for other comorbidities, including anxiety and depression.

Severe UC is a significant problem among children. The drugs available for the treatment of UC include aminosalicylates, corticosteroids, infliximab, and calcineurin inhibitors for induction therapy and aminoslicylates, infliximab, and 6MP/azathioprine for maintenance. While surgery is an option for adolescents with severe UC that is unresponsive to corticosteroids, medical options include infliximab IV, cyclosporine IV, and oral tacrolimus.

The treatment of CD in adolescents differs slightly from adults, as enteral nutrition is more commonly used among children for induction therapy. Other induction options include corticosteroids and anti-TNF agents, with 6MP/azthioprine, methotrexate, and anti-TNF agents used for maintenance. Recent data has shown that enteral nutrition and corticosteroids are similarly efficacious as induction therapies. While biologic agents such as infliximab and adalimumab are effective in pediatric CD, there remain some concerns regarding long-term efficacy. “There has been an increase in the use of biologics in both UC and CD and decrease in the use of steroids in pediatric patients,” said Steven Fitts, MD, of Community Health Network, Indianapolis, IN. “The concern with the use of biologics in pediatric patients is the risk for these drugs to become ineffective when used over the long term. Biologics tend to work for a period of time and patients may develop antibodies and the drug becomes ineffective.”

Bousvaros said that there may be other reasons not to use biologics, including cost, infusion reactions, and loss of response. However, biologics appear to be better than immunomodulators at maintaining steroid-free remission, but thiopurines and methotrexate do work in some patients.

Special situations including growth failure in adolescent IBD should be monitored to avoid chronic inflammation. According to Bousvaros, the three principles of therapy include:

• Maintaining remission by controlling disease activity
• Minimizing corticosteroid use
• Optimizing nutrition using chronic intermittent elemental diet

These interventions are most effective if completed prior to puberty or in the early stages of puberty. In addition, properly timed surgery also treats growth failure in children with CD. Adolescents should also be monitored for the development of anxiety and depression. “Depression and anxiety are common disorders in both healthy adolescents and in adolescents with IBD,” Bousvaros said.

In terms of administration of immunizations, Bousvaros said “good evidence shows that children with IBD respond to inactivated vaccines, even if they are receiving immunosuppressives.” Typically, patients with IBD are under-immunized due to various factors, including concerns with vaccine effectiveness, risk of IBD flare, and concern with adverse events associated with vaccination. Overall, IBD patients should get immunized annually against influenza, receive pneumococcal and meningococcal vaccination as clinically indicated and avoid live vaccines if they are immunocompromised.