Medical therapy for induction and maintenance of remission in pouchitis: Asystematic review

Objective: To determine the effectiveness of medical therapy (including met ronidazole, bismuth carbomer enemas, oral probiotic bacteria, butyrate supp ositories, and glutamine suppositories) for inducing a response or for main taining remission in pouchitis. Search strategy: Studies were selected usin g the MEDLINE data base (1966-December 1997), abstracts from major gastroin testinal meetings, and references from published articles and reviews. Sele ction criteria: Four randomized controlled trials of medical therapy in adu lt patients with pouchitis were identified: two placebo controlled trials i n active chronic pouchitis; one maintenance of remission trial comparing tw o active agents in chronic pouchitis; and one placebo-controlled maintenanc e of remission trial for chronic pouchitis. A single patient "n-of-l" trial for active chronic pouchitis was excluded. Data collection and analysis: D ata were extracted by three independent observers based on the intention to treat principle. Extracted data were converted to 2 x 2 tables (response v ersus no response and medical therapy versus placebo or medical therapy ver sus medical therapy) and an odds ratio with 95% confidence intervals (CI) w ere determined as described by Cochrane and Mantel and Haenszel. In additio n, the absolute risk reduction, relative risk reduction, and number needed to treat were determined. Main results: The odds ratios of inducing a respo nse using oral metronidazole or bismuth carbomer foam enemas compared with placebo in active chronic pouchitis were 12.34 (95% CI 2.34-64.95) and 1.00 (95% CI 0.29-3.42), respectively. The odds ratio of main taining remission in chronic pouchitis for oral probiotic bacteria (VSL-3) compared with pla cebo was 15.33 (95% CI 4.51-52.14). There was no difference in the odds rat io of inducing symptomatic remission and then maintaining symptomatic remis sion after discontinuing suppressive medical therapy for chronic pouchitis with glutamine suppositories compared with butyrate suppositories, 2.75 (95 % CI 0.48-15.94). Conclusions: Metronidazole is an effective therapy for ac tive chronic pouchitis. Bismuth carbomer foam enemas are not effective ther apy for active chronic pouchitis. Oral probiotic therapy with VSL-3 is an e ffective therapy for maintaining remission in patients with chronic pouchit is in remission. There is no difference in maintenance of symptomatic remis sion in patients with chronic pouchitis treated with glutamine versus butyr ate suppositories, and it is unknown whether glutamine and butyrate are equ ally effective or ineffective. Additional randomized, double-blind, placebo -controlled, dose-ranging clinical trials are needed to determine the effic acy of empiric medical therapies currently being used in patients with pouc hitis.