Nationwide Real-World Exclusive Enteral Nutrition Practice Over Time: Persistence of Use as Induction for Pediatric Crohn’s Disease and Emerging Combination Strategy With Biologics

Abstract

Background Exclusive enteral nutrition (EEN) is the recommended first-line induction treatment in pediatric patients with active luminal Crohn’s disease (CD). We aimed to provide a nationwide overview of evolving EEN practices during an era of increasing biologic use. Methods We analyzed a prospectively identified nationwide cohort of newly diagnosed pediatric patients with CD in Scotland between January 1, 2015, and June 30, 2022. Patients who received EEN for any indication were divided into 6-monthly epochs and examined over time. Differences during the COVID-19 pandemic (March 16, 2020, to July 19, 2021) were examined. Data were retrospectively collected from electronic medical records: demographics, anthropometrics, concomitant treatments, aspects of EEN administration, and remission/response rates. Descriptive statistics and linear regression were used for analyses. Results A total of 649 patients with CD were identified (63% male; median age 12.6 [interquartile range, 10.8-14.8] years); 497 (77%) of 649 received EEN as postdiagnosis induction therapy with a median course length of 7.7 (interquartile range, 5.9-8.0) weeks. Including repeat courses, 547 EEN courses were examined. An increasing incidence of CD was observed over time with no significant changes in EEN usage, remission or response rates, nasogastric tube usage, or course completion (all P > .05). Increasing use of EEN combined with biologics (combination induction) as first-line induction was observed over time (P < .001). Considering COVID-19, lower rates of EEN usage were observed (P = .008) with no differences in remission, oral administration, and course completion rates (all P > .05). Conclusions Over the past 7.5 years, except during the COVID-19 pandemic, EEN usage rates have not changed despite an increase in biologic use, although combination induction is an emerging trend.

An update on dietary therapies in paediatric Crohn's disease

“…Over the past few years, there has been a substantial increase in the use of biologic agents, drugs which target specific pathways of the inflammatory response cascade (e.g., antibodies against TNFα), in the treatment of paediatric CD, which may have had an offsetting effect on the use of EEN [15]. Wands et al investigated EEN prescribing practices across Scotland from January 2015 to June 2022 [16]. In this nationwide study, no differences in remission rates were seen based on the type of enteral formula used or whether the course of EEN was the first or a repeated one.…”

Take-Home Messages from 20 Years of Progress in Dietary Therapy of Inflammatory Bowel Disease

“…Since the mechanisms of action of biologics and enteral nutrition are distinct, with the first inhibiting immune system propagation and the second postulated to be excluding dietary disease triggers and how these interact with the gut microbiome, it is possible that combining these two regimes would enhance the primary response to biologic therapy and reduce the risk of secondary loss of response and immunogenicity. We have noted an emerging trend in the use of EEN in combination with biologics in a subcohort of children with severe disease which has emerged over the past few years [42]. The BIOPIC study, a major international multicentre RCT in adults with CD, is currently underway (NCT04859088) to study the effect of monotherapy with anti-TNF alone compared to in combination with PEN.…”