Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease

Abstract

Background and Aim Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research. Methods A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified. Results An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed. Conclusion EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.

Practical Guidance for Dietary Management of Patients With Inflammatory Bowel Disease During the SARS-CoV2 Pandemic

“…37,38 Although the wealth of existing data for EEN is in the pediatric IBD cohort, the same premise for efficacy also applies in adults. 9 In contrast to corticosteroids, immunomodulators, and biologics, EEN poses no immunosuppressive risk of acquiring or becoming severely ill from the novel coronavirus, and thus may be a more suitable alternative to corticosteroids for certain patients with CD. 7,11 See Figure 3 for description of potential benefits and risks of EEN in the current COVID-19 pandemic.…”

“…A multidisciplinary IBD-treating team, including a gastroenterologist and dietitian, is essential during this pandemic for safe EEN application and implementation of dietary strategy with plans for monitoring. 9 With temporary closure of outpatient services, moves toward telehealth, and redirection of resources in some services, patients may have reduced access to their normal services. Therefore, communication between members of the multidisciplinary team is imperative to maintain quality care.…”

“…Beyond the clinical benefits, EEN can also offer a cost-effective alternative to food for patients, particularly if available through health-subsidy programs. 9 EEN may also be delivered directly to the patients, which reduces the need to visit grocery stores in high-risk public environments. Use of EEN may mitigate food insecurity and accessibility, particularly with community stockpiling of food being problematic for certain foods and geographical areas.…”

“…Patients commencing EEN should be managed within multidisciplinary IBD services, with close monitoring and review of treatment efficacy after 2 weeks recommended. 9 …”

“…8 Moreover, EEN has been shown to delay or avoid IBD surgery, which is critical at a time when hospitalization increases risk of COVID-19 exposure as well as in the setting of stretched health care resources. 8,9 Beyond dietary management of IBD, nutritional optimization and evaluation and treatment of both malnutrition and obesity-related illness are important to best equip patients to face COVID-19. 10,11 The need for dietary management of functional gut symptoms, already common in patients with IBD, is likely to increase during this period of enormous psychological stress.…”