加拿大胃肠病学协会儿童肠腔克罗恩病医学治疗临床实践指南。
Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease.
机构信息
Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada.
Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
出版信息
Gastroenterology. 2019 Aug;157(2):320-348. doi: 10.1053/j.gastro.2019.03.022. Epub 2019 Jul 15.
BACKGROUND & AIMS: We aim to provide guidance for medical treatment of luminal Crohn's disease in children.
METHODS
We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them.
RESULTS
The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation.
CONCLUSIONS
Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.
背景与目的
本研究旨在为儿童肠腔型克罗恩病的治疗提供指导。
方法
我们系统地检索了文献数据库，以确定儿科克罗恩病的医学管理研究。根据 GRADE（推荐评估、制定与评估分级）方法，对证据质量和推荐强度进行评级。我们通过迭代在线平台制定声明，然后对其进行最终确定和投票。
结果
共识包括 25 项关于医学治疗选择的声明。由于缺乏证据，另外 14 项声明未能达成共识，也未提出建议。专家组建议使用皮质类固醇治疗（包括布地奈德治疗轻中度疾病）。专家组建议在疾病确诊或早期重度疾病阶段，以及在激素和免疫抑制剂诱导治疗失败的患者中，采用完全肠内营养进行诱导治疗，并采用生物肿瘤坏死因子拮抗剂进行诱导和维持治疗。专家组不建议在中度疾病患者中使用口服 5-氨基水杨酸进行诱导或维持治疗，不建议在诱导治疗中使用硫嘌呤，在维持治疗中使用皮质类固醇，在任何情况下都不建议使用大麻。专家组无法明确界定在开始使用生物制剂时同时使用免疫抑制剂的作用，尽管不建议男性患者使用硫嘌呤联合治疗。对于轻度疾病患者的治疗、诱导或维持治疗中使用抗生素或 vedolizumab、诱导治疗中使用甲氨蝶呤，专家组也未达成共识。正在接受免疫调节剂治疗并处于临床缓解的患者，应在治疗开始后 1 年内评估黏膜愈合情况。
结论
推荐对儿童克罗恩病进行循证医学治疗，并进行持续评估以确定治疗效果。
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