Exclusive Enteral Nutrition Therapy in Paediatric Crohn's Disease Results in Long-term Avoidance of Corticosteroids: Results of a Propensity-score Matched Cohort Analysis

Abstract

Background and aims: Exclusive enteral nutrition [EEN] is recommended as a first-line induction therapy for paediatric Crohn's disease [CD] although corticosteroids [CS] are still used commonly. Our aim was to compare short- and long-term disease outcomes of paediatric CD patients initially managed with either EEN or CS.

Methods: Medical records of newly diagnosed paediatric CD patients treated with EEN or CS as induction therapy were retrospectively reviewed. To minimise selection bias inherent in observational cohort studies, propensity analysis was carried out. Data on anthropometrics, medical history, and presenting phenotype were collected at time of diagnosis [baseline]; outcomes of interest, including medication use, hospitalisation, surgical procedures, and disease progression were assessed up to 6 years following diagnosis.

Results: Of 127 patients reviewed, a total of 111 propensity-score matched CD patients receiving EEN [n = 76] or CS [n = 35] were analysed. By 4-12 weeks of induction therapy, 86.6% of EEN-treated patients achieved remission (Paediatric Crohn's Disease Activity Index [PCDAI] ≤ 7.5) compared with 58.1% of patients in the CS-treated group [p < 0.01]. Choice of EEN over CS for induction was associated with avoidance of corticosteroids over a 6-year follow-up period. Analysis of long-term linear growth, hospitalisation, need for biologic therapy, or surgical intervention did not reveal any significant differences.

Conclusions: These findings suggest that EEN induction therapy is more effective in achieving early remission and is associated with long-term steroid avoidance without increased use of biologics or need for surgery.

Keywords: EEN; corticosteroids; propensity score.

Figure 1.

Clinical response to initial treatment with CS or EEN therapy in newly-diagnosed paediatric CD patients. A. PCDAI scores of CS- or EEN-treated patients at baseline [BSL] and 4–12 weeks post-treatment. B. Percentage of CS- or EEN-treated patients in remission [PCDAI ≤ 7.5] at 4–12 weeks. C. Laboratory values for albumin, ESR, and platelets. D. Percentage of CS- or EEN-treated patients in remission treated with or without concomitant immunomodulator [IMM] within 4 weeks of induction. ***p ≤ 0.001; **p ≤ 0.01; *p < 0.05. CS, corticosteroid; EEN, exclusive enteral nutrition; SD, standard deviation; PCDAI, Paediatric Crohn’s Disease Activity Index; CD, Crohn’s disease; ESR, erythrocyte sedimentation rate.

Figure 2.

Biologic and steroid use in CS- and EEN-treated CD patients by maximum follow-up. A. Percentage of patients treated with CS or EEN at diagnosis who received anti-TNF therapy by maximum follow-up. B. Kaplan-Meier curve showing time from diagnosis to first use of anti-TNF therapy. C. Percentages of EEN-treated patients who remained steroid-naïve, with or without anti-TNF exposure by 2, 4, and 6 years’ follow-up. D. Percentages of EEN-treated patients exposed to steroids by maximum follow-up who were: not exposed to anti-TNF; or received first exposure to steroids before or after first exposure to anti-TNF. CS, corticosteroid; EEN, exclusive enteral nutrition; CD, Crohn’s disease; TNF, tumour necrosis factor.

Figure 3.

Comparison of linear growth outcomes between CS- and EEN-treated CD patients. A. Height z-scores [Htz] of patients treated with CS or EEN at diagnosis and 1,2, 4, and 6 years’ follow-up. B. Changes in height z-scores [ΔHtz] relative to baseline assessment in patients treated with CS or EEN at 1, 2, 4, and 6 years’ follow-up. Data are shown as mean ± standard error of the mean [SEM]. **p < 0.01. CS, corticosteroid; EEN, exclusive enteral nutrition; CD, Crohn’s disease.