Puchitis – Zapobieganie i profilaktyka

Puchitis
Zapobieganie i profilaktyka

Puchitis, zapalenie zbiornika jelitowego po IPAA u pacjentów z wrzodziejącym zapaleniem jelita grubego, dotyka około 50% pacjentów i znacząco obniża jakość życia, zwłaszcza w postaci przewlekłej. Profilaktyka pierwotna obejmuje stosowanie probiotyków, takich jak VSL#3 (De Simone Formulation), które w badaniach wykazały redukcję ostrego puchitis (np. 90% pacjentów bez epizodu w ciągu 12 miesięcy vs 60% w grupie placebo; RR 1,50, 95% CI 1,02-2,21), choć AGA nie rekomenduje ich rutynowego stosowania z powodu ograniczonych danych. Antybiotyki nie są zalecane w profilaktyce pierwotnej, mimo że tinidazol w jednym badaniu wykazał pewne korzyści (81% pacjentów bez epizodu vs 58% placebo; RR 1,38, 95% CI 0,83-2,31). Inne badane substancje, jak allopurinol czy Bifidobacterium longum, nie wykazały istotnej skuteczności.

Puchitis – zapobieganie, profilaktyka

Profilaktyka pierwotna puchitis
Profilaktyka wtórna puchitis
Nowe podejścia w profilaktyce puchitis
Identyfikacja pacjentów z wysokim ryzykiem puchitis
Podsumowanie aktualnych zaleceń
Kolejne rozdziały

Puchitis – zapobieganie, profilaktyka

Puchitis to zapalenie zbiornika jelitowego powstałego po wykonaniu zespolenia jelitowo-odbytniczego (IPAA – ileal pouch-anal anastomosis) u pacjentów z wrzodziejącym zapaleniem jelita grubego. Schorzenie to dotyka około 50% pacjentów po zabiegu IPAA, znacząco wpływając na jakość życia, szczególnie gdy stan zapalny przechodzi w postać przewlekłą¹²³. Istnieje kilka strategii zapobiegania pierwotnego i wtórnego puchitis, które różnią się skutecznością i siłą zaleceń klinicznych.

Profilaktyka pierwotna puchitis

Profilaktyka pierwotna odnosi się do zapobiegania pierwszemu epizodowi puchitis po operacji IPAA. Obecnie dostępne strategie obejmują:

Probiotyki w profilaktyce pierwotnej

American Gastroenterological Association (AGA) w swoich najnowszych wytycznych nie wydaje jednoznacznej rekomendacji za lub przeciw stosowaniu probiotyków w profilaktyce pierwotnej puchitis¹². Wynika to z niewystarczającej ilości danych naukowych wysokiej jakości, które potwierdzałyby skuteczność tej strategii. Eksperci wskazują również na potencjalne koszty i obciążenia związane z długotrwałym stosowaniem probiotyków przy ograniczonych danych o potencjalnych korzyściach².

Niemniej jednak, niektóre badania sugerują potencjalne korzyści ze stosowania określonych szczepów probiotycznych:

Preparat VSL#3 (De Simone Formulation) – w niewielkim badaniu (40 uczestników) 90% (18/20) pacjentów przyjmujących VSL#3 nie doświadczyło ostrego puchitis w ciągu 12 miesięcy obserwacji w porównaniu do 60% (12/20) pacjentów otrzymujących placebo (RR 1,50, 95% CI 1,02-2,21)¹²³.
W innym badaniu, 100% (16/16) pacjentów otrzymujących VSL#3 nie doświadczyło ostrego puchitis w ciągu 12 miesięcy, w porównaniu do 92% (11/12) pacjentów z grupy kontrolnej bez leczenia (RR 1,10, 95% CI 0,89-1,36)¹.
Lactobacillus rhamnosus GG wykazał pewną skuteczność w opóźnianiu pierwszego epizodu puchitis w otwartym badaniu retrospektywnym¹².

Antybiotyki w profilaktyce pierwotnej

AGA wyraźnie zaleca przeciwko stosowaniu antybiotyków w profilaktyce pierwotnej puchitis¹²³. Eksperci podkreślają, że istnieje potrzeba lepszych dowodów z badań klinicznych, które uzasadniałyby użycie antybiotyków jako strategii pierwotnej profilaktyki, szczególnie biorąc pod uwagę potencjalne działania niepożądane i obciążenie związane z długotrwałym stosowaniem przy ograniczonych danych o potencjalnych korzyściach¹.

Warto jednak wspomnieć, że w jednym niewielkim, randomizowanym badaniu kontrolowanym placebo, tinidazol wykazał pewne korzyści w zapobieganiu wystąpieniu puchitis – 81% (21/26) pacjentów leczonych tinidazolem nie doświadczyło żadnych epizodów puchitis w ciągu 12 miesięcy w porównaniu do 58% (7/12) pacjentów otrzymujących placebo (RR 1,38, 95% CI 0,83-2,31)¹².

Inne strategie profilaktyki pierwotnej

Badano również inne substancje i strategie w profilaktyce pierwotnej puchitis:

Allopurinol – w jednym badaniu (184 uczestników) porównano allopurinol z placebo, ale nie wykazano istotnej różnicy w zapobieganiu puchitis (częstość występowania puchitis: 31% vs 28%; p=0,73)¹.
Bifidobacterium longum – badanie z 12 uczestnikami porównujące tę probiotykę z placebo, jednak brak wystarczających dowodów na skuteczność¹.
Clostridium butyricum MIYAIRI – wpływ na zapobieganie puchitis w porównaniu z placebo jest niejasny (1 badanie, 17 uczestników)¹².

Profilaktyka wtórna puchitis

Profilaktyka wtórna odnosi się do zapobiegania nawrotom puchitis u pacjentów, którzy już doświadczyli co najmniej jednego epizodu zapalenia. W tym zakresie dostępne są silniejsze dowody i jaśniejsze rekomendacje.

Probiotyki w profilaktyce wtórnej

AGA zaleca stosowanie probiotyków w zapobieganiu nawracającemu puchitis u pacjentów, którzy doświadczają nawracających epizodów puchitis reagujących na antybiotyki¹². Jest to zalecenie warunkowe, oparte na badaniach z wykorzystaniem preparatu De Simone Formulation (VSL#3)¹.

Dwa podwójnie zaślepione, randomizowane, kontrolowane placebo badania wykazały skuteczność preparatu VSL#3 w utrzymaniu remisji u pacjentów z przewlekłym puchitis, którzy uzyskali remisję po miesięcznej terapii kombinacją antybiotyków¹:

W pierwszym badaniu 40 pacjentów, którzy osiągnęli remisję kliniczną i endoskopową po miesięcznym leczeniu kombinacją antybiotyków (rifaksymina 2 g/dzień + cyprofloksacyna 1 g/dzień), zostało losowo przydzielonych do otrzymywania skoncentrowanego preparatu probiotycznego w dawce 4 saszetki/dzień (18 × 10¹¹ bakterii/dzień) lub placebo przez 9 miesięcy. Wskaźniki remisji po roku wynosiły 85% w grupie probiotycznej i 6% w grupie placebo (p < 0,001)¹.
W innym badaniu u pacjentów otrzymujących profilaktyczne leczenie mieszanką probiotyczną nie zaobserwowano nowych przypadków puchitis podczas leczenia profilaktycznego¹.

Przewlekła antybiotykoterapia

AGA sugeruje stosowanie przewlekłej antybiotykoterapii w leczeniu nawracającego puchitis u pacjentów, u których puchitis odpowiada na antybiotyki, ale nawraca wkrótce po zakończeniu ich przyjmowania (powszechnie określane jako przewlekłe puchitis zależne od antybiotyków)¹². Należy jednak wziąć pod uwagę potencjalne negatywne skutki długotrwałego stosowania antybiotyków, w tym promocję organizmów opornych na leki i ryzyko zakażenia Clostridioides difficile¹.

W badaniu klinicznym rifaksymina wykazała potencjał jako alternatywne leczenie podtrzymujące w zapobieganiu nawrotom puchitis¹².

Zaawansowane terapie immunosupresyjne

Dla pacjentów z nawracającym puchitis, które nie odpowiada na antybiotyki (określane jako przewlekłe puchitis oporne na antybiotyki), AGA sugeruje stosowanie zaawansowanych terapii immunosupresyjnych¹²³. Do tej kategorii należą leki biologiczne i drobnocząsteczkowe:

Leki anty-TNF (np. infliksymab, adalimumab)
Vedolizumab
Ustekinumab
Upadacytynib

Metaanaliza dotycząca skuteczności terapii anty-TNF w przewlekłym opornym na antybiotyki puchitis wykazała, że wskaźniki krótkoterminowej (8 tygodni) i długoterminowej (12 miesięcy) remisji klinicznej wynosiły odpowiednio 0,10 (95% CI, 0,00-0,35) i 0,37 (95% CI, 0,14-0,62)¹.

Kortykosteroidy

AGA sugeruje stosowanie kortykosteroidów u pacjentów z nawracającym puchitis, które nie odpowiada na antybiotyki¹². Szczególnie ilealnie uwalniana budezonida jest zalecana w przypadku choroby zbiornika przypominającej chorobę Crohna, na podstawie pośrednich danych opartych na doświadczeniu ekspertów¹.

Nowe podejścia w profilaktyce puchitis

Transplantacja mikrobioty kałowej (FMT)

Transplantacja mikrobioty kałowej jest obiecującą nową metodą leczenia przewlekłego puchitis¹²³. FMT polega na przeniesieniu normalnej flory jelitowej od zdrowego dawcy do pacjenta ze schorzeniem potencjalnie spowodowanym zaburzeniem homeostazy mikrobioty jelitowej lub dysbiozą. Wcześniejsze badania sugerowały, że manipulowanie składem flory jelitowej poprzez antybiotyki, probiotyki i prebiotyki przynosiło znaczące rezultaty w leczeniu ostrych epizodów puchitis związanego z wrzodziejącym zapaleniem jelita grubego, jednak obecnie nie ma ustalonego skutecznego leczenia przewlekłego puchitis zależnego od antybiotyków¹.

Podejścia dietetyczne

Czynniki dietetyczne mogą odgrywać rolę w zapobieganiu puchitis. Obserwacje wskazują, że:

Zwiększone spożycie owoców i pobieranie antyoksydantów, witaminy A i witaminy C może chronić przed puchitis¹.
Ryzyko puchitis było odwrotnie proporcjonalne do spożycia owoców¹.
Składniki pokarmowe w owocach i warzywach mogą wpływać na funkcję zbiornika poprzez ich wpływ na zawartość wody w jelicie cienkim, pasaż górnego odcinka przewodu pokarmowego oraz strukturę i aktywność fermentacyjną mikrobioty zbiornika¹.
Diety śródziemnomorska i dieta wykluczająca w chorobie Crohna mogą przynieść korzyści wybranym pacjentom jako strategie zapobiegawcze¹.

Inne podejścia zapobiegawcze

Wśród innych strategii zapobiegawczych wymienia się:

Unikanie nadmiernego przyrostu masy ciała po operacji, który wiąże się ze zwiększonym ryzykiem gorszych wyników zbiornika, w tym puchitis¹.
Unikanie leków z grupy NLPZ, w tym aspiryny i ibuprofenu, które mogą powodować zaostrzenia¹.
Aktywność fizyczna, która pomaga zapobiegać zaparciom i utrzymać zdrowie okrężnicy¹.
Przewlekłe stosowanie inhibitorów pompy protonowej (PPI) i antagonistów H2 może zmniejszyć ryzyko puchitis po IPAA w przypadku wrzodziejącego zapalenia jelita grubego¹.

Identyfikacja pacjentów z wysokim ryzykiem puchitis

Istotnym elementem profilaktyki jest identyfikacja pacjentów z wysokim ryzykiem rozwoju puchitis, szczególnie jego przewlekłej postaci. Do czynników ryzyka należą:

Wcześniejsza ekspozycja na leki anty-TNF¹.
Ekspozycja na antybiotyki w roku poprzedzającym ostatni etap IPAA¹.
Pozajelitowe manifestacje choroby, szczególnie pierwotne stwardniające zapalenie dróg żółciowych (PSC)¹².
Rozległe zapalenie okrężnicy przed operacją¹.

Identyfikacja pacjentów ze zwiększonym ryzykiem rozwoju przewlekłego puchitis może umożliwić wczesną interwencję, zmniejszając obciążenie chorobą¹. Znajomość czynników ryzyka przewlekłego puchitis może prowadzić do bardziej spersonalizowanej opieki nad pacjentem, lepszego poradnictwa przedoperacyjnego i potencjalnych interwencji mających na celu zmniejszenie ryzyka przewlekłego puchitis u pacjentów poddawanych operacji IPAA z powodu wrzodziejącego zapalenia jelita grubego¹.

Podsumowanie aktualnych zaleceń

Profilaktyka puchitis jest istotnym elementem opieki nad pacjentami po zabiegu IPAA. Obecne zalecenia AGA obejmują:

Brak jednoznacznej rekomendacji za lub przeciw stosowaniu probiotyków w profilaktyce pierwotnej puchitis¹².
Zalecenie przeciwko stosowaniu antybiotyków w profilaktyce pierwotnej puchitis¹²³.
Zalecenie stosowania probiotyków (szczególnie preparat VSL#3/De Simone Formulation) w zapobieganiu nawracającemu puchitis u pacjentów, którzy doświadczają nawracających epizodów puchitis reagujących na antybiotyki¹²³.
Zalecenie stosowania cyklicznej lub prawie ciągłej antybiotykoterapii w leczeniu puchitis, które odpowiada na antybiotyki, ale często nawraca krótko po zaprzestaniu ich stosowania¹².
Zalecenie stosowania zaawansowanych terapii immunosupresyjnych lub kortykosteroidów u pacjentów z nawracającym puchitis, które nie odpowiada na antybiotyki¹².

Pomimo rosnącej wiedzy na temat profilaktyki puchitis, wciąż istnieje potrzeba lepszych dowodów z badań klinicznych, aby określić optymalną terapię dla zapobiegania i leczenia puchitis¹. Konieczne są dobrze zaprojektowane badania o odpowiedniej mocy statystycznej, aby określić optymalną terapię dla leczenia i zapobiegania puchitis¹.

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Materiały źródłowe

#1 Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis
https://pmc.ncbi.nlm.nih.gov/articles/PMC4917283/
Pouchitis occurs in approximately 50% of patients following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis. […] The primary objective was to determine the efficacy and safety of medical therapies (including antibiotics, probiotics, and other agents) for prevention or treatment of acute or chronic pouchitis. […] Five studies assessed prevention of pouchitis. One study (40 participants) compared VSL#3 to placebo; another (28 participants) compared VLS# 3 to no treatment; one study (184 participants) compared allopurinol to placebo; another (12 participants) compared the probiotic Bifidobacterium longum to placebo; and one study (38 participants) compared tinidazole to placebo. […] The results of one small study (40 participants) suggest that VSL#3 may be more effective than placebo for prevention of pouchitis. Ninety per cent (18/20) of VSL#3 patients had no episodes of acute pouchitis during the 12 month study compared to 60% (12/20) of placebo patients (RR 1.50, 95% CI 1.02 to 2.21). […] For the prevention of pouchitis, low quality evidence suggests that VSL#3 may be more effective than placebo.
#1 Management of pouchitis and inflammatory pouch disorders – American Gastroenterological AssociationAGA Logo_Horizontal
https://gastro.org/clinical-guidance/management-of-pouchitis-and-inflammatory-pouch-disorders/
AGA provides clinical recommendations to guide treatment decisions for patients with pouchitis and inflammatory pouch disorders. […] 1. In patients with ulcerative colitis who undergo IPAA, the AGA makes no recommendation in favor of, or against, the use of probiotics for primary prevention of pouchitis. […] 2. In patients with ulcerative colitis who undergo IPAA, the AGA suggests against using antibiotics for the primary prevention of pouchitis. […] 5. In patients with ulcerative colitis who have undergone IPAA and experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for preventing recurrent pouchitis. […] 6. In patients with ulcerative colitis who have undergone IPAA, and experience recurrent pouchitis that responds to antibiotics but relapses shortly after stopping antibiotics (commonly referred to as chronic antibiotic-dependent pouchitis), the AGA suggests using chronic antibiotic therapy to treat recurrent pouchitis.
#1 Therapy for treatment and prevention of pouchitis | Cochrane
https://www.cochrane.org/CD001176/IBD_therapy-treatment-and-prevention-pouchitis
Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. […] At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). […] Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). […] Eighty-one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence).
#1 Pouchitis: Clinical Features, Diagnosis, and Treatment | IJGM
https://www.dovepress.com/pouchitis-clinical-features-diagnosis-and-treatment-peer-reviewed-fulltext-article-IJGM
In an open, retrospective study, Lactobacillus rhamnosus GG seemed to have some efficacy for delaying the first episode of pouchitis. […] Tinidazole showed some benefit in small, randomized, placebo-controlled trial, published only as an abstract, in prevention of onset of pouchitis; 81% (21/26) of tinidazole patients had no episodes of pouchitis compared to 58% (7/12) of placebo patients during the first year after ileostomy closure. […] Patients with antibiotic-responsive pouchitis could develop frequent relapses and require maintenance therapy. Two double-blind, randomized, placebo-controlled studies have shown the efficacy of De Simone Formulation to maintain remission in patients with chronic pouchitis who obtained remission after 1 month of therapy with antibiotic combination. […] In the first study 40 patients who went into clinical and endoscopic remission after 1 month of combined antibiotic treatment (rifaximin 2 g/day + ciprofloxacin 1 g/day) were randomized to receive either the highly concentrated probiotic preparation, 4 packets/day (18 1011bacteria/day), or placebo for 9 months. Remission rates at 1 year were 85% in the probiotic group and 6% in the placebo group (p 0.001).
#1 AGA Management of Pouchitis and Inflammatory Pouch Disorders Clinical Guidelines Summary – Guideline Central
https://www.guidelinecentral.com/guideline/3352810/
In patients with ulcerative colitis (UC) who undergo IPAA, the AGA makes no recommendation in favor of, or against, the use of probiotics for primary prevention of pouchitis. […] There is a need for better evidence from clinical trials to inform the use of probiotics as a primary prevention strategy for pouchitis, especially given the potential cost and burden of long-term use with limited data on potential benefits. […] In patients with UC who undergo IPAA, the AGA suggests against using antibiotics for the primary prevention of pouchitis. […] There is a need for better evidence from clinical trials to inform the use of antibiotics as a primary prevention strategy for pouchitis, especially given the potential adverse effects and burden of long-term use with limited data on potential benefits.
#1
https://link.springer.com/article/10.1007/s11605-023-05841-3
This systematic review explored different medications and methods for prevention and treatment of pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). […] Probiotics are effective in preventing pouchitis after IPAA. […] One trial investigated the prophylactic role of allopurinol in preventing pouchitis and found a comparable incidence of pouchitis in the two groups (31% vs 28%; p=0.73). […] A meta-analysis of 7 trials on probiotics revealed significantly lower odds of pouchitis with the use of probiotics (RR: 0.26, 95% CI: 0.16-0.42, I2=20%, p<0.001) and similar odds of adverse effects to placebo (RR: 2.43, 95% CI: 0.11-5.9, I2=0, p=0.579). [...] Gionchetti P, Rizzello F, Venturi A, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology. 2003;124:1202-1209. https://doi.org/10.1016/s0016-5085(03)00171-9.
#1 Therapy for treatment and prevention of pouchitis | Cochrane
https://www.cochrane.org/CD001176/IBD_therapy-treatment-and-prevention-pouchitis
It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). […] However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). […] It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants), Bifidobacterium longum and placebo (1 study, 12 participants), allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). […] The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.
#1
https://www.visbiome.com/blogs/news/de-simone-formulation-named-in-aga-clinical-practice-guidelines-on-management-of-pouchitis-and-inflammatory-pouch-disorders?srsltid=AfmBOoqUa45iQDokUEOkTc4C1A_fUFWSVTAg0xny7a6H4p-KSvtc8AIj
Pouchitis is an inflammatory condition that may occur in patients who have undergone an ileal pouch anal anastomosis (IPAA). […] Within their newly updated recommendations for prevention of pouchitis, the AGA guidelines suggests using probiotics for preventing recurrent pouchitis, specifically citing the De Simone Formulation as the multi-strain probiotic utilized in the clinical trials they reviewed to devise this recommendation. […] In summary, the AGA guidelines highlighted that this data supports utilizing the De Simone Formulation for preventing the recurrence of pouchitis in antibiotic-responsive patients, noting that the recommendation is conditional.
#1 Key Focus Areas in Pouchitis Therapeutic Status: A Narrative Review
https://ijms.sums.ac.ir/article_50229.html
Pouchitis, as the most common complication after ileal pouch-anal anastomosis (IPAA), has an incidence from 7% to 46%. […] Changes in dietary components and administration of complementary and alternative medicine, probiotics, and fecal transplantation in addition to conventional therapies have been recommended for pouchitis treatment. […] A probiotic mixture as prophylaxis after the first episode of pouchitis was recommended to reduce the risk of developing pouchitis. […] In 31 pouchitis patients receiving prophylaxis treatment with a probiotic mixture and a group of patients without any treatment, no new case of pouchitis was observed during prophylaxis treatment. […] In 40 patients who achieved remission with antibiotics and received 6 g/day probiotic mixture for prevention of new episodes, only 15% of patients developed chronic pouchitis.
#1 AGA Publishes New Pouchitis Management Guideline | MDedge
https://www.mdedge.com/gihepnews/article/267325/ibd-intestinal-disorders/aga-publishes-new-pouchitis-management-guideline
Because of a knowledge gap, the guideline makes no recommendation for or against use of probiotics for either the primary prevention or treatment of pouchitis. […] In contrast with the above statements, the guideline recommends usage of probiotics to prevent recurrent pouchitis in patients with recurrent, antibiotic-responsive pouchitis. […] Although the guideline supports antibiotics for prevention of pouchitis, the panelists noted that only one randomized controlled trial supports this recommendation, and negative effects of long-term usage need to be considered, including promotion of drug-resistant organisms and risk of Clostridioides difficile infection. […] For patients with recurrent pouchitis that relapses shortly after discontinuing antibiotics, chronic antibiotics should be considered, according to the guideline.
#1 Inflammatory pouch disease: The spectrum of pouchitis
https://www.wjgnet.com/1007-9327/full/v21/i29/8739.htm
Long-term administration of the probiotic VSL#3 has been shown to be effective in maintaining antibiotic-induced pouchitis remission in 85% of treated patients in a 9-mo period. However, other studies have failed to confirm this beneficial effect of VSL#3. Rifaximin may be an alternative maintenance treatment.
#1 Management of pouchitis and inflammatory pouch disorders – American Gastroenterological AssociationAGA Logo_Horizontal
https://gastro.org/clinical-guidance/management-of-pouchitis-and-inflammatory-pouch-disorders/
7. In patients with ulcerative colitis who have undergone IPAA, and experience recurrent pouchitis which responds to antibiotics but relapses shortly after stopping antibiotics (commonly referred to as chronic antibiotic-dependent pouchitis), the AGA suggests using advanced immunosuppressive therapies to treat recurrent pouchitis. […] 8. In patients with ulcerative colitis who have undergone IPAA, and experience recurrent pouchitis with inadequate response to antibiotics (commonly referred to as chronic antibiotic-refractory pouchitis), the AGA suggests using advanced immunosuppressive therapies. […] 9. In patients with ulcerative colitis who have undergone IPAA, and experience recurrent pouchitis with inadequate response to antibiotics (commonly referred to as chronic antibiotic-refractory pouchitis), the AGA suggests using corticosteroids.
#1 Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment
https://irjournal.org/journal/view.php?doi=10.5217/ir.2020.00047
A recent meta-analysis regarding the efficacy of anti-TNF therapy on chronic refractory pouchitis, the rates of short-term (8 weeks) and long-term (12 months) clinical remission were 0.10 (95% CI, 0.000.35) and 0.37 (95% CI, 0.140.62), respectively. […] Studies to improve pouch outcomes are essential and, as presented in this review, could begin with investigating a proactive monitoring protocol.
#1 AGA Clinical Guidelines on the Management of Pouchitis and Inflammatory Pouch Disorders
https://www.hcplive.com/view/aga-clinical-guidelines-management-pouchitis-inflammatory-pouch-disorders
For primary prevention, the authors of the guideline provide no recommendation on the use of probiotics against primary prevention of pouchitis. The authors reported a knowledge gap, with very low-quality evidence. […] The guideline authors also recommended against the use of antibiotics for primary prevention for similar reasons. […] However, the authors of the guidelines did suggest that probiotics can be used for the secondary prevention of pouchitis. […] The authors of the guidelines did recommend for the use of chronic antibiotics in the treatment of Chronic Antibiotic Dependent Pouchitis. […] The guidelines also suggest for the use of advanced therapies in chronic antibiotic dependent pouchitis (CADP) and chronic antibiotic refractory pouchitis (CARP.) […] The authors offered no recommendation regarding the use of Mesalamine for the treatment of CARP. […] The authors do recommend the use of ileal-released budesonide for Crohns-like disease of the pouch based on no studies, but with indirect data based on expert experience.
#1 the Prophylaxis of Recurrent Pouchitis After Fecal Microbiota Transplant in UC With Ileo-anal Anastomosis | Clinical Research Trial Listing
https://www.centerwatch.com/clinical-trials/listings/NCT03524352/the-prophylaxis-of-recurrent-pouchitis-after-fecal-microbiota-transplant-in-uc-with-ileo-anal-anastomosis?country=France&city=Clichy%2525252520Cedex
Fecal microbiota transplantation (FMT) is a novel therapy to transfer normal intestinal flora from a healthy donor to a patient with a medical condition potentially caused by disrupted homeostasis of intestinal microbiota or dysbiosis. […] Previous studies suggested that manipulating the composition of intestinal flora through antibiotics, probiotics, and prebiotic achieved significant results for treating acute episodes of UC-associated pouchitis. […] However, currently there is no established effective treatment for chronic antibiotic dependent pouchitis. Our project aims to evaluate the delay of relapse in chronic recurrent pouchitis after FMT versus sham transplantation.
#1 Inflammatory pouch disease: The spectrum of pouchitis
https://www.wjgnet.com/1007-9327/full/v21/i29/8739.htm
Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is the operation of choice for refractory ulcerative colitis (UC), for UC with dysplasia, and for familial adenomatous polyposis (FAP). […] The prevention of pouchitis begins in the operative room during surgical construction of the pouch. A suitable-sized, not too long pouch, is less susceptible to pouchitis. Excessive weight gain postoperatively has been associated with an increased risk for worse pouch outcomes, including pouchitis. Moreover, the increase in fruit consumption and intake of antioxidants, vitamin A, and vitamin C may protect from pouchitis. The use of probiotics, i.e., VSL#3, has been shown to be beneficial in the primary prevention of pouchitis. The administration of Lactobacillus rhamnosus GG has also shown to be effective in the primary prophylaxis. However, these treatments are expensive and the long-term benefit or safety is as yet unknown.
#1 Key Focus Areas in Pouchitis Therapeutic Status: A Narrative Review
https://ijms.sums.ac.ir/article_50229.html
Dietary components in fruits and vegetables can affect pouch function through their impact on small bowel water content, upper gastrointestinal transit, and the structure and fermentative activity of the pouch microbiota. The risk of pouchitis was inversely related to the intake of fruits. […] Fecal microbiota transplantation is a promising new treatment for chronic pouchitis; and changing fecal microbiome in patients with chronic pouchitis can lead to beneficial outcomes.
#1 Chronic pouchitis: what every gastroenterologist needs to know | Frontline Gastroenterology
https://fg.bmj.com/content/16/2/143
Emerging therapies like anti-TNF monoclonal antibodies, vedolizumab, ustekinumab and small molecules show promise for refractory cases. […] Dietary therapies (including the Mediterranean and Crohns disease exclusion diets) and probiotics may also benefit select patients as preventative strategies.
#1 Pouchitis – What You Need to Know
https://www.drugs.com/cg/pouchitis.html
How can I manage or prevent pouchitis? […] Do not take NSAID medicines, including aspirin and ibuprofen. NSAIDs can cause flare-ups. […] Eat a variety of healthy foods. Healthy foods include fruit, vegetables, whole-grain breads, low-fat dairy products, beans, lean meat, and fish. Your healthcare provider or a dietitian can help you create a meal plan that is right for you. […] Drink liquids as directed. Ask how much liquid to drink each day and which liquids are best for you. For most people, water, juice, and milk are good choices. Do not drink alcohol. Alcohol can make your symptoms worse. […] Be physically active, as directed. Physical activity helps prevent constipation and keep your colon healthy. Ask about the best exercise plan for you.
#1 Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis
https://eurekaselect.com/public/article/99875
Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. […] Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. […] In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients. […] Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. […] Long-term use of probiotics Lactobacillus and Bifidobacterium has a prophylactic effect on the occurrence and severity of pouchitis: a randomized prospective study. […] Delay of the first onset of pouchitis by oral intake of the probiotic strain Lactobacillus rhamnosus GG. […] Chronic use of PPI and H2 antagonists decreases the risk of pouchitis after IPAA for ulcerative colitis. […] The effect of Clostridium butyricum MIYAIRI on the prevention of pouchitis and alteration of the microbiota profile in patients with ulcerative colitis.
#1 Identifying patients at high risk for chronic pouchitis – Medical Conferences
https://conferences.medicom-publishers.com/specialisation/gastroenterology/ecco-2025/identifying-patients-at-high-risk-for-chronic-pouchitis/
Prior anti-TNF exposure and antibiotic exposure in the year before the final stage of ileal pouch-anal anastomosis (IPAA) were associated with an increased risk of developing chronic pouchitis. […] These findings indicate that it is possible to identify patients at increased risk for chronic pouchitis and that secondary prevention may play a part in decreasing the burden of this condition. […] In this way, we may be able to intervene early, reducing the burden of disease, stated Dr Barnes.
#1 Risk factors associated with the development of chronic pouchitis following ileal-pouch anal anastomosis surgery for ulcerative colitis
https://www.wjgnet.com/2308-3840/full/v13/i1/101226.htm
Chronic pouchitis remains a significant and prevalent complication following ileal pouch-anal anastomosis in patients with ulcerative colitis. […] To identify potential risk factors for the development of chronic pouchitis. […] Extraintestinal manifestations, PSC and extensive colitis are associated with the development of chronic pouchitis. These findings underscore the importance of comprehensive pre-operative assessment and tailored post operative management strategies. […] Identifying the risk factors of chronic pouchitis could lead to more personalized patient care, better preoperative counselling, and potential interventions to reduce the risk of chronic pouchitis in patients undergoing IPAA surgery for ulcerative colitis in the future and improve long-term outcomes. […] The aim of this study is to assess factors, including demographic and clinical characteristics, as well as pathology-based variables, for the development of chronic pouchitis after IPAA surgery in patients with UC.
#1 First comprehensive medical guideline on management of pouchitis released – American Gastroenterological AssociationAGA Logo_Horizontal
https://gastro.org/press-releases/first-comprehensive-guideline-on-management-pouchitis/
AGA suggests initial treatment of pouchitis with antibiotics. […] Treatment with multi-strain probiotics following an antibiotic course is suggested for preventing recurrent pouchitis. […] AGA suggests cyclical or near continuous antibiotic therapy to treat pouchitis that responds to antibiotics but recurs frequently and shortly after antibiotics are discontinued. […] In patients with recurrent pouchitis that doesnât respond to antibiotics or Crohnâs-like disease of the pouch, AGA suggests advanced immunosuppressive medications (ie. Infliximab, vedolizumab, ustekinumab, upadacitinib, etc.). […] The AGA guideline suggests against use of antibiotics for primary prevention of pouchitis, and guideline authors did not find enough scientific evidence to recommend for or against the use of probiotics for prevention.
#1 Treatment and prevention of pouchitis after ileal pouchâanal anastomosis for chronic ulcerative colitis – Holubar, SD – 2010 | Cochrane Library
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001176.pub2/abstract
Pouchitis may occur following ileal pouchanal anastomosis for chronic ulcerative colitis in approximately 30% of patients. […] The primary objective was to determine the efficacy of medical therapies for pouchitis (including antibiotic, probiotic, and other agents) as substantiated by data from randomized controlled trials (RCTs). […] Randomized controlled treatment or prevention trials of adult patients who underwent ileal pouchanal anastomosis for ulcerative colitis who subsequently developed pouchitis or were at risk for pouchitis were considered for inclusion. […] For the prevention of pouchitis (3 RCTs, 2 agents), in one study VSL#3 was more effective than placebo while in another study VSL#3 was not more effective than no treatment. […] For the prevention of pouchitis, VSL#3 was more effective than placebo. […] Larger RCTs are needed to determine the optimal agent(s) for the treatment and prevention of pouchitis.
#2 Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis
https://eurekaselect.com/public/article/99875
Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. […] Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. […] In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients. […] Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. […] Long-term use of probiotics Lactobacillus and Bifidobacterium has a prophylactic effect on the occurrence and severity of pouchitis: a randomized prospective study. […] Delay of the first onset of pouchitis by oral intake of the probiotic strain Lactobacillus rhamnosus GG. […] Chronic use of PPI and H2 antagonists decreases the risk of pouchitis after IPAA for ulcerative colitis. […] The effect of Clostridium butyricum MIYAIRI on the prevention of pouchitis and alteration of the microbiota profile in patients with ulcerative colitis.
#2 AGA Management of Pouchitis and Inflammatory Pouch Disorders Clinical Guidelines Summary – Guideline Central
https://www.guidelinecentral.com/guideline/3352810/
In patients with ulcerative colitis (UC) who undergo IPAA, the AGA makes no recommendation in favor of, or against, the use of probiotics for primary prevention of pouchitis. […] There is a need for better evidence from clinical trials to inform the use of probiotics as a primary prevention strategy for pouchitis, especially given the potential cost and burden of long-term use with limited data on potential benefits. […] In patients with UC who undergo IPAA, the AGA suggests against using antibiotics for the primary prevention of pouchitis. […] There is a need for better evidence from clinical trials to inform the use of antibiotics as a primary prevention strategy for pouchitis, especially given the potential adverse effects and burden of long-term use with limited data on potential benefits.
#2 Therapy for treatment and prevention of pouchitis | Cochrane
https://www.cochrane.org/CD001176/IBD_therapy-treatment-and-prevention-pouchitis
Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. […] At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). […] Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). […] Eighty-one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence).
#2 First comprehensive medical guideline on management of pouchitis released – American Gastroenterological AssociationAGA Logo_Horizontal
https://gastro.org/press-releases/first-comprehensive-guideline-on-management-pouchitis/
AGA suggests initial treatment of pouchitis with antibiotics. […] Treatment with multi-strain probiotics following an antibiotic course is suggested for preventing recurrent pouchitis. […] AGA suggests cyclical or near continuous antibiotic therapy to treat pouchitis that responds to antibiotics but recurs frequently and shortly after antibiotics are discontinued. […] In patients with recurrent pouchitis that doesnât respond to antibiotics or Crohnâs-like disease of the pouch, AGA suggests advanced immunosuppressive medications (ie. Infliximab, vedolizumab, ustekinumab, upadacitinib, etc.). […] The AGA guideline suggests against use of antibiotics for primary prevention of pouchitis, and guideline authors did not find enough scientific evidence to recommend for or against the use of probiotics for prevention.
#2 Pouchitis: Clinical Features, Diagnosis, and Treatment | IJGM
https://www.dovepress.com/pouchitis-clinical-features-diagnosis-and-treatment-peer-reviewed-fulltext-article-IJGM
The probiotic preparation De Simone Formulation has been shown to prevent pouchitis onset within the first year after surgery in a randomised, double-blind, placebo-controlled study. Forty consecutive patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were randomized to receive either the probiotic formulation (2 packets containing 450 billion bacteria of different 8 strains each/day) (n = 20) or an identical placebo (n = 20) immediately after ileostomy closure for 1 year. The patients were assessed clinically, endoscopically, and histologically after 1, 3, 6, 9, and 12 months. Two of the 20 patients (10%) treated with the probiotic formulation had an episode of acute pouchitis compared with 8 of the 20 patients (40%) treated with placebo (Log rank test, z = 2.273; P 0.05), and experienced a significant improvement in their quality of life.
#2 AGA Management of Pouchitis and Inflammatory Pouch Disorders Clinical Guidelines Summary – Guideline Central
https://www.guidelinecentral.com/guideline/3352810/
In patients with UC who have undergone IPAA and experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for preventing recurrent pouchitis. […] Implementation consideration: De Simone formulation of multistrain probiotics was used in clinical trials of prevention of pouchitis.
#2 Rifaximin for the Secondary Prevention of Recurrent Pouchitis
https://ctv.veeva.com/study/rifaximin-for-the-secondary-prevention-of-recurrent-pouchitis
Although many people will develop recurrent pouchitis (inflammation of the ileal pouch-anal anastomosis or J-pouch after colectomy for ulcerative colitis) after an initial episode of pouchitis, there are currently no effective treatments to prevent recurrent pouchitis. […] The goal of this study is to evaluate the potential for rifaximin, an antibiotic, to prevent recurrent pouchitis after treatment for an initial episode of pouchitis. […] This study will examine whether people are willing to take rifaximin for one year with the goal of preventing recurrent pouchitis. […] The information gained through this study will potentially be helpful in improving the ability to prevent recurrent pouchitis in patients who have a colectomy for ulcerative colitis.
#2 Ulcerative Colitis Resource Center
https://www.healio.com/news/gastroenterology/20231219/first-comprehensive-guideline-on-pouchitis-management-aims-to-have-direct-impacts-on-care
The AGA advises against use of antibiotics for the primary prevention of pouchitis. […] Probiotics may be used to prevent recurrent episodes of antibiotic-responsive pouchitis. […] Among patients with UC who have undergone IPAA, the AGA advises against use of antibiotics for the primary prevention of pouchitis. Conversely, antibiotics are suggested for those who experience infrequent episodes of pouchitis. […] Probiotics may be used to prevent recurrent pouchitis among those who experience recurrent, antibiotic-responsive episodes. […] The AGA suggests chronic antibiotic therapy or advanced immunosuppressive therapy for treatment of recurrent pouchitis among patients who responded to antibiotics but relapsed shortly after stopping treatment. […] Among those who experience recurrent pouchitis with inadequate response to antibiotics, the AGA suggests use of advanced immunosuppressive therapies or corticosteroids. […] The AGA also suggests use of corticosteroids or advanced immunosuppressive therapy among patients who develop symptoms due to Crohns-like disease of the pouch.
#2 the Prophylaxis of Recurrent Pouchitis After Fecal Microbiota Transplant in UC With Ileo-anal Anastomosis | Clinical Research Trial Listing
https://www.centerwatch.com/clinical-trials/listings/NCT03524352/the-prophylaxis-of-recurrent-pouchitis-after-fecal-microbiota-transplant-in-uc-with-ileo-anal-anastomosis?country=France&city=Clichy%2525252520Cedex
Fecal microbiota transplantation (FMT) is a novel therapy to transfer normal intestinal flora from a healthy donor to a patient with a medical condition potentially caused by disrupted homeostasis of intestinal microbiota or dysbiosis. […] Previous studies suggested that manipulating the composition of intestinal flora through antibiotics, probiotics, and prebiotic achieved significant results for treating acute episodes of UC-associated pouchitis. […] However, currently there is no established effective treatment for chronic antibiotic dependent pouchitis. Our project aims to evaluate the delay of relapse in chronic recurrent pouchitis after FMT versus sham transplantation.
#2 How to Manage Pouchitis in Ulcerative Colitis?
https://eurekaselect.com/public/article/19818
It is estimated that 50% of patients who have undergone ileal pouch anal anastomosis (IPAA) surgery for UC will develop at least one episode of pouchitis. […] The risk of developing pouchitis is much higher in patients with preoperative extraintestinal manifestations and primary sclerosing cholangitis. […] Starting maintenance treatment with highly concentrated probiotics is recommended as primary and secondary prophylaxis.
#3 Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment
https://irjournal.org/journal/view.php?doi=10.5217/ir.2020.00047
Pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. […] The standard proactive monitoring of pouch inflammation and surveillance of pouch neoplasia must be established for IBD patients after proctocolectomy with IPAA. […] A recent retrospective study showed that smoking cessation may increase the risk of pouchitis although active smoking does not seem to be preventive for pouchitis. […] The concentrated probiotic mixture VSL#3 was also reported to prevent acute pouchitis developed within the first year after surgery. […] If a combination of oral antibiotics fail to induce or maintain remission, oral or topical mesalamine, corticosteroids, anti-TNF drugs including infliximab and adalimumab are shown to be effective for chronic pouchitis.
#3 Pouchitis: Clinical Features, Diagnosis, and Treatment | IJGM
https://www.dovepress.com/pouchitis-clinical-features-diagnosis-and-treatment-peer-reviewed-fulltext-article-IJGM
The probiotic preparation De Simone Formulation has been shown to prevent pouchitis onset within the first year after surgery in a randomised, double-blind, placebo-controlled study. Forty consecutive patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were randomized to receive either the probiotic formulation (2 packets containing 450 billion bacteria of different 8 strains each/day) (n = 20) or an identical placebo (n = 20) immediately after ileostomy closure for 1 year. The patients were assessed clinically, endoscopically, and histologically after 1, 3, 6, 9, and 12 months. Two of the 20 patients (10%) treated with the probiotic formulation had an episode of acute pouchitis compared with 8 of the 20 patients (40%) treated with placebo (Log rank test, z = 2.273; P 0.05), and experienced a significant improvement in their quality of life.
#3 Ulcerative Colitis Resource Center
https://www.healio.com/news/gastroenterology/20231219/first-comprehensive-guideline-on-pouchitis-management-aims-to-have-direct-impacts-on-care
The AGA advises against use of antibiotics for the primary prevention of pouchitis. […] Probiotics may be used to prevent recurrent episodes of antibiotic-responsive pouchitis. […] Among patients with UC who have undergone IPAA, the AGA advises against use of antibiotics for the primary prevention of pouchitis. Conversely, antibiotics are suggested for those who experience infrequent episodes of pouchitis. […] Probiotics may be used to prevent recurrent pouchitis among those who experience recurrent, antibiotic-responsive episodes. […] The AGA suggests chronic antibiotic therapy or advanced immunosuppressive therapy for treatment of recurrent pouchitis among patients who responded to antibiotics but relapsed shortly after stopping treatment. […] Among those who experience recurrent pouchitis with inadequate response to antibiotics, the AGA suggests use of advanced immunosuppressive therapies or corticosteroids. […] The AGA also suggests use of corticosteroids or advanced immunosuppressive therapy among patients who develop symptoms due to Crohns-like disease of the pouch.
#3 Key Focus Areas in Pouchitis Therapeutic Status: A Narrative Review
https://ijms.sums.ac.ir/article_50229.html
Dietary components in fruits and vegetables can affect pouch function through their impact on small bowel water content, upper gastrointestinal transit, and the structure and fermentative activity of the pouch microbiota. The risk of pouchitis was inversely related to the intake of fruits. […] Fecal microbiota transplantation is a promising new treatment for chronic pouchitis; and changing fecal microbiome in patients with chronic pouchitis can lead to beneficial outcomes.
#3 Azthena logo with the word Azthena
https://www.news-medical.net/news/20231219/AGA-releases-the-first-comprehensive-evidence-based-guideline-on-management-of-pouchitis.aspx
AGA suggests initial treatment of pouchitis with antibiotics. […] Treatment with multi-strain probiotics following an antibiotic course is suggested for preventing recurrent pouchitis. […] The AGA guideline suggests against use of antibiotics for primary prevention of pouchitis, and guideline authors did not find enough scientific evidence to recommend for or against the use of probiotics for prevention.
#3
https://www.visbiome.com/blogs/news/de-simone-formulation-named-in-aga-clinical-practice-guidelines-on-management-of-pouchitis-and-inflammatory-pouch-disorders?srsltid=AfmBOoqUa45iQDokUEOkTc4C1A_fUFWSVTAg0xny7a6H4p-KSvtc8AIj
Pouchitis is an inflammatory condition that may occur in patients who have undergone an ileal pouch anal anastomosis (IPAA). […] Within their newly updated recommendations for prevention of pouchitis, the AGA guidelines suggests using probiotics for preventing recurrent pouchitis, specifically citing the De Simone Formulation as the multi-strain probiotic utilized in the clinical trials they reviewed to devise this recommendation. […] In summary, the AGA guidelines highlighted that this data supports utilizing the De Simone Formulation for preventing the recurrence of pouchitis in antibiotic-responsive patients, noting that the recommendation is conditional.