The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Current management
The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Current management
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DOI：
10.1016/j.crohns.2009.12.002
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发表时间：
2010-02-01
影响因子：
8
通讯作者：
Travis, S. P. L.
中科院分区：
文献类型：
--
作者：
Dignass, A.;Van Assche, G.;Travis, S. P. L.
克罗恩病患者的管理计划应考虑到疾病的活动，部位和行为，并应始终与患者讨论。确定疾病的活动性在克罗恩病中可能比溃疡性结肠炎更困难，因为症状（如疼痛或腹泻）可能是由于活动性疾病以外的原因造成的。因此，应始终考虑肠道感染、脓肿、细菌过度生长、胆盐吸收不良、动力障碍（IBS）或胆结石等症状的其他解释。缺铁性贫血应该被发现和治疗，因为它可能解释疲劳或嗜睡的症状。一些治疗决定可能不得不在不知道疾病的全部分布的情况下做出，特别是在那些患有严重疾病的患者中。经验表明，临床医生往往对疾病活动性判断不佳;因此，在开始或改变药物治疗之前，应获得疾病活动性的客观证据（炎症标志物或结肠镜检查）。这一概念得到了克罗恩病生物和免疫调节剂初治患者研究（SONIC）的支持，在该研究中，入组试验时有活动性疾病内镜证据的患者的治疗获益显著更高。1药物的适当选择受以下因素的影响：药物效力和潜在副作用之间的平衡;既往治疗反应（特别是在考虑复发治疗或类固醇依赖性或难治性疾病治疗时）;以及肠外表现或并发症的存在。不同的制剂在不同的部位释放，可能具有局部活性（如美沙拉秦制剂和布地奈德），因此最好根据患者个体进行选择。重要的是要记住，选定的轻度疾病患者的一个选择是不开始活性治疗，因为在临床试验的系统性综述中，18%（95% CI 14-24%）的患者在单独接受安慰剂时进入缓解。[2]因此，让患者参与所有的治疗决策显然很重要。
The management plan for a patient with Crohn's disease should take into account the activity, site and behaviour of disease, and should always be discussed with the patient. Determining the activity of disease may be more difficult in Crohn's disease than ulcerative colitis, since symptoms (such as pain or diarrhoea) may be due to causes other than active disease. Therefore, alternative explanations for symptoms such as enteric infection, and abscess, bacterial overgrowth, bile salt malabsorption, dysmotility (IBS), or gall stones should always be considered. Iron deficiency anaemia should be identified and treated, since it may explain symptoms of fatigue or lethargy. Some treatment decisions may have to be made without knowing the full distribution of disease, especially in those patients with severe disease. Experience has shown that clinicians are often poor judges of disease activity; therefore objective evidence of disease activity should be obtained (inflammatory markers or colonoscopy as appropriate) before starting or changing medical therapy. This concept is supported by the Study of Biologic and Immunomodulator Naive Patients in Crohn's Disease (SONIC), in which the benefit of therapy was significantly higher in those patients with endoscopic evidence of active disease at entry to the trial. 1The appropriate choice of medication is influenced by the balance between drug potency and potential side-effects; previous response to treatment (especially when considering treatment of a relapse, or treatment for steroid-dependent or-refractory disease); and the presence of extraintestinal manifestations or complications. Different preparations are released at different sites and may have local activity (such as mesalazine preparations and budesonide), so the choice is best tailored to the individual patient. It is important to remember that one option for selected patients with mild disease would be to start no active treatment, as in a systematic review of clinical trials, 18%(95% CI 14–24%) of patients entered remission when receiving placebo alone. 2 Thus it is clearly important to involve patients in all therapeutic decisions.