Crohn’s disease exclusion diet + partial enteral nutrition in paediatric Crohn’s disease

In a multicentre, randomised, controlled trial, Crohn's disease exclusion diet (CDED) + partial enteral nutrition (PEN) showed superior tolerance and sustained remission compared with exclusive enteral nutrition (EEN) in children with mild-to-moderate luminal Crohn’s disease [1]. Thus, it could be used as first-line therapy for children with luminal mild-to-moderate active Crohn’s disease.

Dr Arie Levine (Mount Saint Vincent University, Canada) explained that emerging data suggests a strong environmental component in the pathogenesis of Crohn’s disease, and an important role of the microbiota. He also explained that if the dietary factors that drive inflammation could be identified and removed from the diet, inflammation could be reduced and remission induced without requiring EEN by using an exclusion diet with whole foods. This was the study’s incentive to compare CDED + PEN with EEN in a 12-week prospective, international trial in 78 children from 13 sites aged 6-18 years with a paediatric Crohn’s disease activity index (PCDAI) ≥10, and elevated inflammatory markers. The combination therapy aimed to reduce exposure to dietary components hypothesised to negatively affect the microbiome, intestinal barrier, and innate immunity. The primary endpoint was tolerance to diet; secondary endpoints included week 6 intention to treat (ITT) remission defined by PCDAI ≤10 after 6 weeks, and corticosteroid free ITT-sustained remission after 12 weeks.

In 74 analysed patients, tolerance was significantly better in the CDED + PEN group: 97.5% vs 73.7% (P=0.003). Poor compliance was similar in both groups: 17.5% vs 23.5% (P=0.52). Dr Levine found the difference in remission surprising:

• week 6 ITT corticosteroid-free remission (PCDAI ≤10) occurred in 80% in the CDED group vs 73.5% in the EEN group (P=0.51);
• more strictly defined remission (PCDAI <10) was seen in 75% vs 59% (P=0.38); and
• sustained corticosteroid-free free remission at week 12 (PCDAI ≤10) was 70% vs 41.2% (P=0.01).

“These are convincing data for induction of remission and for sustaining remission with CDED + PEN in mild-to-moderate active Crohn’s disease in children,” Dr Levine said. “They also convincingly show that diet reduces inflammation and that re-exposure to diet increases inflammation and reduced sustained remission.” The outcomes support a mechanism whereby inflammation is induced by Proteobacteria-led dysbiosis, remission by a decline in Proteobacteria with expansion of Firmicutes, and loss of remission by rapid return of dysbiosis with exposure of food. “The outcomes support using CDED + PEN for 12 weeks as a first-line therapy to replace EEN in mild-to-moderate active Crohn’s disease in children.”

1. Van Limbergen J, et al. ECCO 2019, OP05.

Posted on 9 May, 20198 April, 2024