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Budesonide Prolongs Time to Relapse in Ilealand

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Budesonide Prolongs Time to Relapse in Ilealand 82 Gut 1996; 39: 82-86 Budesonide prolongs time to relapse in ileal and ileocaecal Crohn's disease. A placebo controlled one year study Gut: first published as 10.1136/gut.39.1.82 on 1 July 1996. Downloaded from R L6fberg, P Rutgeerts, H Malchow, C Lamers, A Danielsson, G Olaison, D Jewell, 0 0stergaard Thomsen, H Lorenz-Meyer, H Goebell, H Hodgson, T Persson, C Seidegard Abstract Corticosteroids are the most efficacious Background and Ains-To evaluate the medical treatment for active Crohn's disease efficacy and safety of the topical cortico- (CD)' with remission rates of 50 to 80 per cent steroid budesonide, given in an oral con- reported after short or intermediate courses of trolled release formulation for treatment.2A Well known adverse effects (for maintenance ofremission in patients with example, acne, moon face, hirsutism, buffalo ileal and ileocaecal Crohn's disease (CD). hump) and systemic side effects (that is, impact Patients and Methods-Out of 176 patients on adrenal gland function, hypertension, with active CD who had achieved remis- impaired glucose tolerance) make continued sion (CD activity index score s,S0) after 10 conventional corticosteroid treatment with high weeks' treatment with either budesonide or doses inadvisable. Some patients achieving prednisolone, 90 were randomised to remission with the use of corticosteroids, how- continue with once daily treatment of6 mg ever, may benefit from longterm treatment with budesonide, or 3 mg budesonide or placebo low doses (<7.5 mg/day) of prednisolone or for up to 12 months in a double blind, similar. In the European Cooperative CD multicentre trial. Time to symptomatic study3 a subgroup of patients with active CD relapse was calculated using Kaplan-Meier being brought into remission with 6-methyl- estimates. Morning plasma cortisol was prednisolone fared better during low dose, measured at clinic visits and a corti- longterm maintenance treatment than patients cotropin stimulation test was performed treated with placebo. after three months oftreatment. The potent and topically acting cortico- http://gut.bmj.com/ Results-Thirty two patients were allo- steroid budesonide has recently been proved to cated to the 6 mg budesonide group, 31 to be efficacious for induction of remission in the 3 mg group, and 27 to the placebo patients with ileal and ileocaecal CD in two group. After three months, 19 per cent of large controlled trials.5 6 Budesonide caused the patients in the 6 mg group had significantly less suppression of adrenal gland relapsed, compared with 45 per cent in the function, and consequently fewer cortico- 3 mg group and 44 per cent in the placebo steroid associated side effects, compared with a on September 23, 2021 by guest. Protected copyright. group (p=0.047). The corresponding standard regimen of prednisolone.5 results after 12 months was 59 per cent in The aim of this study was to determine if the 6 mg budesonide group, 74 per cent in budesonide given in an oral controlled release the 3 mg group, and 63 per cent in the preparation would safely prolong the time placebo group (p=0.44). The median time in remission, as induced by corticosteroids, to relapse or discontinuation was 258 days in CD patients during a one year, placebo in the 6 mg group, 139 days in the 3 mg controlled trial. group, and 92 days in the placebo group (p=0.021). Mean morning plasma cortisol values increased from entry in all three Methods groups with no statistically significant differences at 12 months. All 13 patients Study design remaining in the placebo group after three This was a randomised, double blind, months had a normal corticotropin placebo controlled study with three parallel stimulation response, compared with 18 groups. Patients entering the trial had been of 23 patients in the 6 mg, and 19 of 21 in treated during 10 weeks with either budes- the 3 mg budesonide groups (p=0.14). onide or prednisolone for active CD in a Acne and moon face were slightly more preceding study.5 Eligible patients for this common in the budesonide groups. study had to be in remission, defined as a CD Conclusion-6 mg budesonide once daily activity index (CDAI) score2 of 150 or less, is significantly more efficacious than after 10 weeks of treatment in the above men- Correspondence to: and were then Associate Professor placebo in prolonging time to relapse in tioned short-term study, they R Lofberg, Unit of CD, and causes only minor systemic side offered to continue with the relapse preven- Gastroenterology, Karolinska that started afterwards. Institute, Huddinge effects. tive part directly University Hospital, (Gut 1996; 39: 82-86) Patients were randomly allocated to treat- S-141 86 Huddinge, ment with either budesonide, 3 mg or 6 mg Sweden. once daily, or placebo for up to 12 months. Accepted for publication Keywords: budesonide, corticosteroid, corticotropin 31 January 1996 hormone, cortisol, Crohn's disease. The patients were followed up as outpatients Budesonide for maintenance ofremission in Crohn 's disease 83 with scheduled visits after three, six, nine, Laboratory assessments and 12 months of treatment. At each visit blood samples were taken for clinical chemistry and haematology analyses at each study centre (including: haemoglobin, Patients packed cell volume, white blood cell count Patients aged 18 years or more, with an with differential, platelets, sodium, potassium, Gut: first published as 10.1136/gut.39.1.82 on 1 July 1996. Downloaded from established diagnosis of CD localised to the calcium, creatinine, glucose, bilirubin, alkaline terminal ileum or ileocaecal region were eligible phosphatase, alanine aminotransferase, aspar- for the trial. Patients gave their written or verbal tate aminotransferase, albumin, erythrocyte informed consent. sedimentation rate, C reactive protein). Patients with septic complications, active At each visit a blood sample was taken inflammation of the rectum, active systemic between 8 and 10 am for analysis of plasma infection or peptic ulcer disease were excluded. cortisol concentrations. A short corticotropin Patients with diabetes mellitus, or a random stimulation test was also performed after three blood glucose exceeding 8 mmol per litre were months in the study. Samples for assessment also excluded, as were patients with signifi- of plasma cortisol values were taken 30 and cant hepatic, renal or cardiovascular disease. 60 minutes after an intravenous bolus injec- Patients were not eligible if they were receiving tion of 0.25 mg synthetic corticotropin total parenteral, enteric or polymeric nutrition, hormone (Synacthen). All plasma samples if they had an ileostomy or previous small were analysed in a blinded manner at Astra bowel resection exceeding 100 cm. Draco, Lund using a high performance liquid chromatography method.8 Study drugs The budesonide gelatin capsules (Entocort Treatment plan capsules, Astra Draco AB, Lund, Sweden) Patients included in the study were randomly contained acid stable microgranules of budes- allocated to one of three treatment groups; 6 onide in ethylcellulose coated with a layer of mg budesonide daily, or 3 mg daily, or placebo acrylic based resin (Eudragit L100-55), which for up to 12 months. The patients were dissolves at a pH above 5-5. The formulation randomised at each centre in blocks of six. was designed to release budesonide during Eleven centres in six European countries passage through the ileum and the ascending participated in the trial. colon.7 Each capsule contained 3 mg ofbudes- Patients were treated until a symptomatic onide. Placebo capsules of identical appear- relapse as judged by an increase of the CDAI ance were manufactured by Astra Draco. The score occurred, either as calculated at a planned http://gut.bmj.com/ drugs were provided in blister packages, which or at an extraordinary visit. Treatment was dis- had to be returned at the next visit to the clinic. continued if surgery for CD became necessary, Unopened blisters were counted to determine if a septic complication occurred, ifthe patient's compliance. Non-compliance was defined as condition significantly deteriorated or if the more than 25 per cent of doses unused. patient became pregnant. No concurrent active medication for CD such as other corticosteroids, sulphasalazine, on September 23, 2021 by guest. Protected copyright. olsalazine or 5-aminosalicylic acid, metronida- Statistical and ethical considerations zole or immunosuppressants was permitted Based on data from the European cooperative during the study. Antidiarrhoeal drugs such as CD study,3 a relapse rate ofat least 50 per cent loperamide, diphenoxylate or other opiates was expected in the placebo group after 12 were permitted. The use ofcholestyramine was months. With 30 patients in each treatment permitted if the dose was kept constant group there would be an 80 per cent probabil- throughout the study. ity of detecting a difference between any active treatment and placebo if the budesonide group only had a relapse rate of 13 per cent. Clinical assessments The analyses were based on all patients The patients' CDAI score was calculated at treated using the last value extended princi- each visit to the clinic. Patients were provided ple, which was applied from the visit at three with diary cards to record their general well months to the final visit at 12 months. The being, number of loose stools, abdominal pain primary variables studied were relapse rate or fever. Relapse was defined as CD activity and time to relapse or treatment discontinua- index score > 150 together with an increase ofat tion. One way analysis ofvariance was used to least 60 units from entry. Relapse in this context compare changes in CDAI and other quanti- also included any patient withdrawn from tative variables between the three groups. the study due to an acute deterioration The x2 test was applied to compare relapse that required other drug treatment or a surgical rates, and survival analysis in the form of procedure, whether or not a CDAI score the generalised Wilcoxon test was used for calculation was available at that time.
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