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P341. Steroids may reduce the benefit of exclusive enteral feeding in paediatric Crohn's disease

J.-P. Gonçalves, L. Quaresma, H. Rego, A. Ratola, M. Tavares, E. Trindade, J. Amil, Hospital S. João, Department of Pediatric Gastroenterology Hepatology & Nutrition, Porto, Portugal

Background

Exclusive enteral nutrition (EEN) is the standard recommendation for treatment of paediatric active Crohn's disease, but for many years steroids (CT) were used to induce remission. On the transition to the new protocol (EEN), for some time we used a combination of EEN plus low dose steroids in an attempt to induce earlier well-being and benefit from the appetite stimulation from steroids to increase acceptance of the diet.

All 3 regimens proved to be effective in inducing clinical remission but it was not clear which would cause longer remission. To assess that we compared the 3 groups of patients (G1: CT; G2: EEN+CT; G3: EEN).

Methods

Among 99 new diagnosed active CD pediatric cases, clinical and laboratory data of 63 patients were retrospectively (1999–2013) reviewed, and the following data were recorded: demography, PCDAI at diagnosis and at 8, 12 and 52 weeks, additional therapy, and CD relapses.

Results

In this study 63 cases were included and classified in the 3 treatment groups: 19 received CT, 11 EEN and 33 EEN plus CT. In G1 the steroid dose was 1 mg/kg/day; G2 received exclusive polymeric formula for 8 weeks (1500–2000 ml/day), and G3 received a combination of EEN (full dose) plus steroids (0.5 mg/kg/d, max 20 mg). For the majority, azathioprine was started in the first 8 weeks after diagnosis.

There was no difference in age, initial PCDAI (G1 25; G2 20; G3 25), dose or timing of starting azathioprine or 5-ASA among the 3 groups. Of the 23 (36.5%) children who have relapsed in the follow-up: 10 received CT, 12 received CT+EEN, and 1 received EEN (p = 0.058). All patients went into clinical remission at week 8 but the relapse rate of G1 (52.6%) and G2 (36.4%) during the first year was similar while G3 had lower relapse rate (9.1%). In G1, the relapse occurred at a median (min-max) time of 21.5 (8–52) weeks, in G2 it occurred at 22.5 (12–52) (p = 0.619) and the single relapse in G3 occurred at 20 weeks. There was no significant difference in azathioprine dose.

Biologics were required in 18.2% of G1, 9.7% of G2 group and none in G3. In 6 patients a second relapse was observed.

Conclusion

To our knowledge this is the first observation comparing the clinical effect of combination of EEN with low dose steroids and the observed results suggest that the addition of any dose of steroids to EEN may counteract the proven benefit of mucosal healing. Although these data are preliminary and group sizes are unequal there is a clear different outcome at 52 weeks. We speculate that steroids may interfere with the mucosal healing induced by polymeric diet reducing it and predisposing patients to earlier relapse of CD.