Dietary therapies

IBD Curriculum Topic 12.1-12.3, 12.5

Nutritional therapy usually represents enteral polymeric feeds, but includes elemental enteral feeds and parenteral nutrition (TPN); ω-3 fatty acids; nutritional supplements; and probiotics. 

Benefit & risk (Crohn's Disease)

Response and remission

  • No placebo-controlled trials exist.
  • Exclusive nutritional therapy can induce remission, but is inferior to corticosteroid therapy (NNT = 4), with no difference between polymeric and elemental diets.
  • Enteral nutrition can be used to treat Crohn’s disease in patients who decline or have contraindications to corticosteroids.
    • May be particularly beneficial in children and young adults.
    • Compliance is the major hurdle – close liaison between patient and dietician helps.
  • Provide adjunctive nutritional support to patients with > 10% weight loss or body mass index < 18.
  • TPN may be required in complex, internal fistulising disease; or those with high out-put (> 1 L/d) fistula
  • There is no convincing evidence that pro- or pre-biotics are of value in Crohn’s disease.

Maintenance of remission

  • The efficacy for ω-3 fatty acids remains controversial and is not supported by the two largest placebo controlled trials, EPIC-1 and EPIC-2.
  • There is insufficient evidence to support probiotics as maintenance treatment in Crohn’s disease.
  • There is insufficient evidence (2 small trials) to support using enteral nutritional supplementation

Benefit & risk (Ulcerative Colitis)

  • Trichuris suis ova improve remission but not response rates in a small study. This needs confirmation in a larger study.
  • The evidence for heparin, and for leucocytapheresis is tenuous or conflicting.
  • There is no robust evidence for probiotics inducing or maintaining remission. One placebo-controlled study of a probiotic (VSL#3) reported improved clinical response rates. A trial in 29 children reported that addition of the probiotic VSL#3 enhanced remission and maintenance rates; no well-powered studies have been undertaken.E. coli strain Nissle 1917, 200 mg/d (≈50x109) may be equivalent to 5-ASA for maintenance treatment (ECCO 6G, beneath).
  • There are small studies, though no clear benefit, assessing acupuncture, Boswellia serrate gum, germinated barley, aloe vera.
  • 2g curcumin added to 5-ASA maintenance therapy may improve response rates in maintenance therapy.
  • Faecal transplantation has been shown to modify patients’ microbiota, becoming more diverse and more similar to those of their donors. A trial (published in 2017) of 81 patients underwent placebo enemas or FT from several donors, 5 days a week for 8 weeks; 27% patients reached steroid-free clinical and endoscopic remission at Week 8 compared with 8% with placebo [p = 0.02].

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