Long-term PEN therapy promising in children with mild Crohn’s disease

Partial enteral nutritional (PEN) therapy shows potential in the long-term management of mild paediatric Crohn’s disease (CD), helping to avoid the use of corticosteroids and prevent side effects commonly observed with other inflammatory bowel disease (IBD) therapies, according to a study presented at the virtual Crohn's & Colitis Congress (CCC 2022).

In a retrospective analysis of 49 young CD patients, PEN was initiated for primary induction (n=30, 61 percent) and to avoid other medications (n=26, 53 percent); for some, PEN was given after failure of primary medical therapy (n=10, 20 percent). Partially hydrolyzed formulas (n=30, 61 percent) were the commonly chosen formula type for PEN therapy, followed by standard formulas with whole intact proteins (n=16, 33 percent). [CCC 2022, abstract P108]

The PEN persistence rate was 51 percent (n=26) at year 1 and dropped to 25 percent (n=12) at year 2. The median time on PEN was 1.3 years (interquartile range, 0.6–2.2 years). Most patients discontinued therapy due to disease relapse or progression (n=32/41,78 percent), while others were nonadherent to PEN (n=8/41, 20 percent). A small number of patients had formula intolerance (n=3/41, 7 percent).

After PEN was discontinued, about half of the patients were started on infliximab (n=21/41, 51 percent) while some received adalimumab (n=8/41, 20 percent).

The mean age of the study population was 11.4 years at CD diagnosis and 12.1 years at PEN initiation. Most patients were male (n=30, 61 percent) and White (n=38, 77 percent). None of them had diagnoses of ulcerative colitis or indeterminate colitis and received concomitant treatment with systemic steroids (prednisone [or equivalent] dose >20 mg daily), biologics, or immunomodulators.

Lead study author Dr Srisindu Vellanki from the Children's Hospital of Philadelphia in Philadelphia, US, revealed that a secondary analysis is in the works to identify predictors of response or failure to PEN therapy, such as disease location/distribution, type of formula, and the amount of calories from food vs formula.

Preferable to exclusive enteral nutrition

“PEN (defined as 80 percent of daily caloric intake from formula) has shown similar efficacy in inducing remission for paediatric CD in comparison to exclusive enteral nutrition (EEN, defined as 100 percent of daily caloric intake from formula),” said Vellanki.

Since EEN provides adequate nutritional intake of all macro- and micronutrients over a sufficiently long period, it cannot only improve the nutritional status of patients but also alleviate inflammation. Some reports claim that when it comes to mucosal healing induction in paediatric patients, EEN seems to be even more effective than corticosteroid therapy. [Aliment Pharmacol Ther 2017;46:645-656; Cochrane Database Syst Rev 2018;4:CD000542; Benedik E. Partial Enteral Nutrition in Crohn’s Disease. In: Ahmed M, ed. Crohn’s Disease Recent Advances. IntechOpen: doi:10.5772/intechopen.91501 2021]

However, as its name suggests, EEN limits consumption to enteral formulas while avoiding other foods over a period of 6–8 weeks. It lowers the quality of life, and many patients find this unacceptable. Furthermore, for some who accept oral EEN poorly, feeding must be done via a nasogastric tube.

PEN emerged to address the constraints associated with EEN. Unlike the latter, PEN allows patients to consume some ordinary food besides the enteral formula, either unrestricted or in a form of specified elimination diets, as a way to increase compliance and adherence. Therefore, all patients who are not adherent to EEN and those who do not want to receive corticosteroids due to their several side effects represent the ideal candidates for PEN. [Benedik E. Partial Enteral Nutrition in Crohn’s Disease. In: Ahmed M, ed. Crohn’s Disease Recent Advances. IntechOpen: doi:10.5772/intechopen.91501 2021]