Other Agents

Anedoctal reports have suggested that oral or topical conventional corticosteroids may be of benefit to patients with pouchitis. Recently a double-blind, double-dummy, 6-week-controlled trial investigated the efficacy and tolerability of budesonide enema in the treatment of pouchitis compared with oral metronidazole. This study showed that budesonide enemas (2 mg/100 ml at bedtime) have a similar efficacy as oral metronidazole (0.5 g bid) in terms of disease activity, clinical and endoscopic findings (58 and 50% of patients, respectively, improved with a decrease in PDAI score ^3), but less side-effects (25 vs. 57%) and better tolerability, representing consequently a valid therapeutic alternative for active pouchitis [37].

While no data have been published on the efficacy of oral 5-ASA, uncontrolled studies have suggested the efficacy of topical 5-ASA either as suppositories or enemas in treatment of acute pouchitis [38]. As concerns immunosuppressive agents, cyclosporine enemas have been reported to be successful in chronic pouchitis in a pilot study [39] and other small studies have suggested that oral azathioprine may also be useful.

The observation reported in some studies [40], but not all [41], that the faecal concentration of SCFAs is lower in patients with pouchitis, led to the hypothesis that the topical administration of nutrients, such as SCFAs or butyrate or glutamine, may produce clinical benefit. Poor clinical results were obtained in uncontrolled trials using SCFAs enemas [42-43]. In a 3-week double-blind trial, glutamine and butyrate suppositories were compared in a group of 19 patients with chronic pouchitis with recurrent symptoms; the end-point was clinical remission. As the relapse rate was 40% for the glutamine group and 67% for the butyrate group and no placebo group was included, it was almost impossible to state if the two treatments were both ineffective and similarly effective [44]. In consideration of all these studies, nutritional therapy thus far should not be considered beneficial for pouchitis.

Bismuth, effective in UC and traveller's diarrhoea because of its anti-microbial and anti-diarrhoeal effects, was also investigated. One open-label long-term study evaluated the efficacy and safety of bismuth-citrate carbomer enemas in achieving and maintaining remission in a group of patients with chronic treatment-resistant pouchitis. After 45 days of nightly treatment, 83% of patients went into remission with a significant decrease of the mean total PDAI score from 12 to 6. Moreover, these patients entered a maintenance phase with enemas administered every third night for 12 months (60%) were able to maintain remission for 12 months [45]. On the other hand, a double-blind randomised trial in patients with active chronic pouchitis did not find a difference between bismuth enemas and placebo [46]. More recently, a 4-week treatment open trial showed patients benefited from bismuth subsalicy-late tablets administered for chronic antibiotic-resistant pouchitis [47].

Allopurinol, a scavenger of oxygen-derived free radicals through inhibition of xanthine oxidase, was evaluated as post-operative prophylactic treatment (100 mg twice daily) against pouchitis in a randomised placebo-controlled double-blind study conducted at 12 centres in Sweden; however, it was not proven to be able to reduce the risk of a first attack of pouchitis [48].

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