diagnostic and treatment algorithms of ulcerative colitis ... · diagnostic and treatment...
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UKRAINIAN MEDICAL STOMATOLOGICAL ACADEMYUKRAINIAN MEDICAL STOMATOLOGICAL ACADEMY
Professor IGOR SKRYPNYKProfessor IGOR SKRYPNYK
DIAGNOSTIC AND TREATMENT ALGORITHMS OF ULCERATIVE COLITIS
IN UKRAINE
DIAGNOSTIC AND TREATMENT ALGORITHMS OF ULCERATIVE COLITIS
IN UKRAINE
ACTUALITYACTUALITYStandards of diagnostics and treatment of Standards of diagnostics and treatment of ulcerative colitis (UC) in Ukraine are based ulcerative colitis (UC) in Ukraine are based on world generally accepted approaches on world generally accepted approaches and include differentiated stage prescription and include differentiated stage prescription of preparations in dependence on:of preparations in dependence on:
spreading of pathological process;spreading of pathological process;
character of the course of the disease. character of the course of the disease.
PREVENTING RELAPSES
REDUCING DISEASE ACTIVITY
DIMINISHING OF EXPRESSED CLINICALSYMPTOMS
IMPROVING PATIENTS’ QUALITY OF LIFE
The traditional tasks of treatment are:
The traditional tasks of treatment are:
ПЕРЕД НАЧАЛОМЛЕЧЕНИЯ!It is important to estimate
possibilities of therapy taking the following into account:
- localization and gravity of process;- activity of process;- presence of complications;- response to the previously applied therapy.
To present the individual chart of patient’s treatment:- 1-st line of therapy- 2-nd line of therapy
To estimate the prospect of applied therapy
It is important to estimate It is important to estimate possibilities of therapy taking possibilities of therapy taking the following into accountthe following into account::
- localization and gravity of process;- activity of process;- presence of complications;- response to the previously applied therapy.
To present the individual chart of patientTo present the individual chart of patient’’s treatments treatment::- 1-st line of therapy- 2-nd line of therapy
To estimate the prospect of applied therapyTo estimate the prospect of applied therapy
BEFORE THE BEGINNING OF TREATMENT
BEFORE THE BEGINNING OF TREATMENT
AminosalicylatesAminosalicylates (5(5--ААSASA//SPS)SPS)
CorticosteroidsCorticosteroids
ImmunosupImmunosuppresantspresants
((AZA/MTX)AZA/MTX)
Biological Biological therapytherapy ((IFX)IFX)
ООppее--rrааtiontion
II lineline
IIII lineline
T H E R A P YT H E R A P YT H E R A P Y
DIAGNOSISDIAGNOSIS
5-ASA (mildly or moderate course)
Supporting therapy
AbsenceAbsenceof effectof effect
CS
Absence Absence of effectof effect, , increase increase
of activityof activity СS +immunomodula-tors (moderate, severe activity)
More aggressive therapy СSwith/or without
immunomodulators(severe activity)
Immunomo-dulators
Operativetreatment
KornbluthKornbluth A, et alA, et al.Am J Gastroenterol..Am J Gastroenterol.2004:13712004:1371--1385.1385.XuXu CC--T, et al. T, et al. World J GastroenterolWorld J Gastroenterol.2004;10:1416.2004;10:1416--1421.1421.Becker JM. Becker JM. GastroenterolGastroenterol Clinics North AmClinics North Am.1999;28:371.1999;28:371--390.390.
TREATMENT ALGORITHMSTREATMENT ALGORITHMS
DISEASE ACTIVITYDISEASE ACTIVITY
DISEASE ACTIVITYDISEASE ACTIVITY
DIFFICULTIES OF THERAPY ARE:
DIFFICULTIES OF THERAPY ARE:
2525--30% patients are resistant to the 30% patients are resistant to the basic therapy with standard dosesbasic therapy with standard doses
the side effects of systemic the side effects of systemic glucocorticoidsglucocorticoids and and immunosuppressant are forecastedimmunosuppressant are forecasted
BASIC DIAGNOSTIC AND MEDICAL PRINCIPLES OF ULCERATIVE COLITIS
BASIC DIAGNOSTIC AND MEDICAL PRINCIPLES OF ULCERATIVE COLITIS
Detecting localization, activity and
complications
Detecting localization, activity and
complications
Excluding intercurrent
diseases
Excluding intercurrent
diseases
Evaluating the efficiency of the
previously applied therapy
Evaluating the efficiency of the
previously applied therapy
Prescribing preparations having
well-proven efficiency and high safety level
Prescribing preparations having
well-proven efficiency and high safety level
T. Andus, 2003T. Andus, 2003
PRINCIPLESPRINCIPLES
THE ULTIMATE GOAL OF PATIENTS’TREATMENT
THE ULTIMATE GOAL OF PATIENTS’TREATMENT
NOWADAYSNOWADAYSNOWADAYS
Prophylaxis or reducing complications
Prophylaxis or reducing complications
«Convalescence» of mucous membrane
«Convalescence» of mucous membrane
Removing or improving complaints and symptoms
Removing or improving complaints and symptoms
Development of etiotropictherapy
Development of etiotropictherapy
FUTUREFUTUREFUTURE
DESIGN OF INVESTIGATIONDESIGN OF INVESTIGATION25 pts with the moderate course of the active distal 25 pts with the moderate course of the active distal UC (the index of clinical activity 6UC (the index of clinical activity 6--12; 12; endoscopicendoscopicindex index –– 4 according to 4 according to RachmilewitzRachmilewitz, 1989) divided , 1989) divided intointo 3 groups depending on curative complexes: 3 groups depending on curative complexes:
group I (n=9) group I (n=9) –– mesalazinemesalazine (tablets) 3 g/day (tablets) 3 g/day and and budesonidebudesonide 9 mg/day for three taking; 9 mg/day for three taking;
group II (n=8) group II (n=8) –– mesalazinemesalazine ((granulsgranuls) 3 g/day ) 3 g/day and and budesonidebudesonide 9 mg/day for one taking; 9 mg/day for one taking;
group III (n=8) group III (n=8) –– mesalazinemesalazine ((granulsgranuls) 3 g/day ) 3 g/day and and budesonidebudesonide 9 mg/day for one taking and 9 mg/day for one taking and rebamipiderebamipide 300 mg/day300 mg/day
CLINICAL AND ENDOSCOPIC REMISSION
after 8-week treatmentCLINICAL AND ENDOSCOPIC
REMISSION after 8-week treatment
55 (62,5%)(62,5%)
44 (50%)(50%)
3 3 (33,3%)(33,3%)
EndoscopicEndoscopicremissionremission, , numbernumber, %, %
Clinical remission Clinical remission PatientsPatientsgroupsgroups
27,527,5±±1,71,755 (62,5%)(62,5%)Group IIGroup II
30,730,7±±1,81,866 (75%)(75%)Group IIIGroup III
23,723,7±±1,41,45 5 (55,6%)(55,6%)Group IGroup I
durationduration, , daysdaysnumbernumber, %, %
mmоl
/l
BloodBlood
0
1
2
3
І ІІ ІІІ
– normal– before treatment– after treatment
mm
ol/2
4 ho
urs
NАNА concentrationin UC pts
NАNА concentrationin UC pts
UrineUrine
0
1
2
3
4
І ІІ ІІІ
mmоl
/l
BloodBlood
0
0,2
0,4
0,6
І ІІ ІІІ– normal– before treatment – after treatment
mm
ol/2
4 ho
urs
FUCOSE CONCENTRATIONin UC pts
FUCOSE CONCENTRATIONin UC pts
UrineUrine
0
0,5
1
1,5
І ІІ ІІІ
Rebamipide enema versus 5-ASA enema for distal UC: a randomized controlled trialRebamipide enema versus 5-ASA enema
for distal UC: a randomized controlled trial
1,651,65±±0,580,581,651,65±±0,480,48before treatmentbefore treatmentEndoscopicEndoscopicgrading scalegrading scale 1,21,2±±0,690,691,151,15±±0,480,48after treatmentafter treatment
9,69,6±±1,461,461010,,6565±±0,870,87before treatmentbefore treatmentDisease Disease activity indexactivity index 6,056,05±±3,773,776,66,6±±3,2*3,2*after treatmentafter treatment
7,17,1±±2,022,028,058,05±±2,012,01before treatmentbefore treatmentEndoscopicEndoscopicindex scoreindex score 5,055,05±±2,92,96,06,0±±2,382,38after treatmentafter treatment
6,66,6±±1,691,697,857,85±±1,561,56
55--ASA ASA enemaenema
7,87,8±±1,731,73before treatmentbefore treatmentBiopsy scoreBiopsy score 6,36,3±±1,651,65after treatmentafter treatment
RebamipideRebamipideenemaenema
40 pts with mildly to moderately active distal UC: 40 pts with mildly to moderately active distal UC: group I (n=20) group I (n=20) –– rebamipiderebamipide enema; enema; group II (n=20) group II (n=20) –– 55--ASA enema. ASA enema.
Once a day for 4 weeks.Once a day for 4 weeks.
The efficacy of RE was The efficacy of RE was similar to that of 5similar to that of 5--ASA.ASA. M. Miyata et al., 2006M. Miyata et al., 2006M. Miyata et al., 2006
Efficacy and safety of rebamipideenemas for active UC pts
(a randomized, multicentre pilot study)
Efficacy and safety of rebamipideenemas for active UC pts
(a randomized, multicentre pilot study)19 pts with mild to moderate active distal US19 pts with mild to moderate active distal US
44--week once a day treatmentweek once a day treatmentI groupI group (n=9)(n=9)
1 g of 1 g of mesalazinemesalazine enemaenema+ baseline treatment+ baseline treatment
II groupII group (n=10)(n=10)150 mg of 150 mg of rebamipiderebamipide enemaenema
H. Ogata et al., 2006H. Ogata et al., 2006H. Ogata et al., 2006
The efficacy and safety of RE treatment appears to be The efficacy and safety of RE treatment appears to be egualegual to ME for active distal UC.to ME for active distal UC.R. increase regeneration by enhancing expressionR. increase regeneration by enhancing expressionof intercellular claudinof intercellular claudin--11in colonic epithelial cells.in colonic epithelial cells.
0,160,162,32,3±±1,31,35,85,8±±1,01,0
after after treatmenttreatment
0,080,082,82,8±±1,21,266,,1+1+1,01,0
before before treatmenttreatment
DiseaseDisease activityactivity indexindex Results of treatmentResults of treatmentPatient groupsPatient groups
5 5 (50%)(50%)4 4 (40%)(40%)IIII –– rebamipiderebamipideP.P.
5 5 (55,6%)(55,6%)3 3 (33,3%)(33,3%)ll –– mesalazinemesalazine
clinical clinical improvementimprovement
clinical clinical remissionremission
Increase Increase of of PgEPgE22 in IMMin IMM
Induction of Induction of the the CCООGG--22expressionexpression
Improvement ofImprovement ofmicrocirculation in IMMmicrocirculation in IMM
Stimulation of regeneration of intestine mucous membrane
Improvement of EGFImprovement of EGF andandEGFEGF--receptor expressionreceptor expression
ImprovementImprovementof claudinof claudin--11expressionexpression
↓↓ POLPOLin IMM in IMM
Suppression of Suppression of neutrophilneutrophil functionsfunctions
↑↑ resistance of resistance of IMMIMM
((citoprotectioncitoprotection))
MECHANISMS OF CITOPROTECTIVE EFFECT OF
REBAMIPIDE IN UC pts
MECHANISMS OF CITOPROTECTIVE EFFECT OF
REBAMIPIDE IN UC pts
BUDESONIDE FOR THE TREATMENT OF ACTIVE
DISTAL UC BUDESONIDE
FOR THE TREATMENT OF ACTIVE DISTAL UC
Study designStudy design –– open,randomizedopen,randomized, , multicentermulticenterDurationDuration –– 8 8 weeksweeks
DosageDosage group Igroup I :: 3 3 ccааpsps. 3 . 3 mgmg 3 3 times atimes a dayday ((nn==77))group II group II :: 3 3 capscaps. (9. (9mgmg) 1) 1time a daytime a day ((nn==88))
0,3150,31555 (71%)(71%)33 (38%)(38%)
0,0260,02677 (57%)(57%)
00
Improve of clinical Improve of clinical activity index activity index
Remission Remission
44 (57%)(57%)44 (57%)(57%)Group IIGroup II0,6190,6190,026*0,026*РР
33 (38%)(38%)00Group lGroup l5656--thth dayday2828--thth dayday
Prescribing B. in a dose of 9 mg one-time has an
advantage in comparison with taking 1 caps. 3 times a day.
Prescribing B. in a dose Prescribing B. in a dose of 9 mg oneof 9 mg one--time has an time has an
advantage in comparison with advantage in comparison with taking 1 caps. 3 times a day.taking 1 caps. 3 times a day.
* * -- statistic reliablestatistic reliable
Kolkman et al., 2004KolkmanKolkman et al., 2004et al., 2004
PROTECTIVE EFFECT OF MELATONINE IN COLITIS PROTECTIVE EFFECT OF MELATONINE IN COLITIS
A. Akсan et al., 2008A. Akсan et al., 2008
antioxidant effectimproving the microcirculationstimulating the repair of intestinal epithelium
antioxidant effectimproving the microcirculationstimulating the repair of intestinal epithelium
0
50
100
150
0
10
20
30
40
0
50
100
150
ControlControl ColitisColitis Colitis+Colitis+melatoninemelatonine
nmol
nmol
// mg
mg //
min
min
albu
min
albu
min
UAUA .
/./ grgr
tissu
etis
sue
ControlControl ColitisColitis Colitis+Colitis+melatoninemelatonine
piko
grpi
kogr
/ml
/ml
ControlControl ColitisColitis Colitis+Colitis+melatoninemelatonine
TNF-αendotoxineTNF-αendotoxine
TNF-α and endotoxine, blood serum
TNF-α and endotoxine, blood serum
Caspase-3 activityCaspase-3 activity
Myeloperoxidase activityMyeloperoxidase activity
BASIC FUNCTIONS OFESSENTIAL PHOSPHOLIPIDS
BASIC FUNCTIONS OFESSENTIAL PHOSPHOLIPIDS ААntioxydativentioxydative effecteffectDesagregationalDesagregational effecteffectImmunomodulationImmunomodulation in a cellular levelin a cellular levelRestore of the damaged Restore of the damaged membrane structures of the cellmembrane structures of the cellIncrease of prostaglandins synthesisIncrease of prostaglandins synthesis
HepatoprotectiveHepatoprotective effecteffectStimulation of Stimulation of endogenicendogenicphospholipids synthesisphospholipids synthesis
DEPROTEINATED HEMODERIVATE–removal of tissue hypoxia and improvement
of circulation of blood in to the mucous membrane of intestine
DEPROTEINATED HEMODERIVATE–removal of tissue hypoxia and improvement
of circulation of blood in to the mucous membrane of intestine
increase of energetic potential of cells increase of energetic potential of cells (increase in 5 times of cell consumption (increase in 5 times of cell consumption of glucose)of glucose)
diminishes inflammatorydiminishes inflammatory--cellular cellular infiltration, anabolism actioninfiltration, anabolism action
improves blood supply, removes tissue improves blood supply, removes tissue hypoxiahypoxia
CONCLUSIONCONCLUSION
1. Optimization of the curative 1. Optimization of the curative complexes with the substitution of the complexes with the substitution of the MesalazineMesalazine in tablets on granules, in tablets on granules, especially with additional especially with additional RebamipideRebamipideprescription, in one time daily taking of prescription, in one time daily taking of BudesonideBudesonide leads to rising of the leads to rising of the effectiveness of treatment and effectiveness of treatment and improvement of life spending quality in UC improvement of life spending quality in UC patients. patients.
MODERN APPROACHES TO UC TREATMENT
MODERN APPROACHES TO UC TREATMENT
citoprotectorcitoprotector ((RebamipideRebamipide))bilious acids (bilious acids (UrsodeoxycholicUrsodeoxycholic acid)acid)endogenous matters (Melatonin)endogenous matters (Melatonin)stabilization of membranes stabilization of membranes ((phosphatidilcholinephosphatidilcholine))antihypoxantsantihypoxants (deproteinated hemoderivate)correction of correction of microbiocenosismicrobiocenosis disordersdisorders
Basic therapyBasic therapy «Convalescence»of mucous membrane↑↑ resistance mucous resistance mucous
barrier of intestinebarrier of intestine