Dr. Pardi article

[JLH]

http://www.gastrojournal.org/article/S0 ... ltext#sec6

[tex]

Thanks for the link.

Tex

[JLH]

Thanks for fixing it.

[Mags]

Yikes! Yersinia be the plague! Considering the amount and power of the antibiotics needed to treat bubonic plague, tis no wonder some people get MC!

Almost makes me glad I just had C. Diff.!

Mags

[Mags]

Although, I hope he is referring to Yersinia Enterocolitica, and not Yersina pestis!

(Says the history geek...)



Mags

[Gloria]

IMHO, this report, though dated April 2011, doesn't shed any new light on the treatment of MC. Nowhere is diet mentioned. No wonder the GIs don't get the connection. Plus, they're still calling it an elderly women's disease.

This was interesting, however:

As many as 33% of patients with celiac disease have histologic changes in the colonic mucosa that are consistent with microscopic colitis.101, 102 In a large cohort study of patients with celiac disease, 4.3% were diagnosed with microscopic colitis, which is a rate of diagnosis that is 72-fold greater than for patients without celiac disease.103 Microscopic colitis is therefore more common among patients with celiac disease; it should be considered in the diagnosis of patients who have continued or recurrent diarrhea despite a strict gluten-free diet.

And this:

These data indicate that celiac disease is relatively uncommon among patients with microscopic colitis, and it is probably not necessary to routinely test these patients for celiac disease. However, celiac disease should be considered in treatment-refractory patients and those with significant weight loss, any indication of steatorrhea, or other symptoms such as unexplained iron deficiency anemia.

I wish we had the reimission rates w/o diet changes that they report:

The reported natural history of microscopic colitis varies. The rate of symptomatic remission ranges from 60% to 93% among patients with lymphocytic colitis13, 111 and 2% to 92% among those with collagenous colitis.26, 64, 111, 112 A study reported remission rates of 59% among patients with lymphocytic colitis and 34% among those with collagenous colitis after a 6-month follow-up period, with an additional 25% and 40%, respectively, showing “significant improvement.”37 Another study reported spontaneous remission in 15% and treatment-induced remission in 48% of patients with collagenous colitis after a 3.5-year follow-up period.61 Of the remaining 37% with ongoing disease, only 60% (22% of the entire cohort) required prolonged therapy. In contrast, clinical trials have reported that 12% to 40% of patients respond to placebo after 6 to 8 weeks.113, 114, 115, 116 In contrast, an open-label study of corticosteroid therapy reported that 90% of patients required some form of maintenance therapy.

They don't understand why budesonide (Entocort) doesn't "cure" MC:

Unfortunately, although budesonide is effective for induction therapy, the relapse rate is high once this medication is discontinued15, 117, 122 and many patients become corticosteroid dependent. Therefore, before patients are given corticosteroid therapy, their diagnosis should be reevaluated and alternative diagnoses, such as coexistent celiac sprue or infection, must be excluded.

Thanks for posting, Joan. It seems that the GI field is still in the dark ages.

Gloria

[tex]

Gloria,

Excellent critique! You lamented the fact that he simply can't bring himself to acknowledge that diet might have any bearing on the disease, but for a while, I thought that he was about to make a concession, when I read the paragraph I've quoted below, but nope - you can lead a horse to water, but you can't force him to drink.

Luminal Factors

A variety of luminal factors have been implicated in the pathogenesis of microscopic colitis, including dietary antigens, drugs, bile salts, and bacterial products and toxins. The observation that histologic features associated with microscopic colitis resolve if the fecal stream is diverted by ileostomy indicates the role of luminal factors.12, 55 Dogs develop a histologically similar form of lymphocytic colitis that responds to treatment with a hypoallergenic diet, further implicating luminal dietary substances in pathogenesis.56 The best evidence for the role of luminal factors in human microscopic colitis is that, among patients with microscopic colitis who also have celiac disease, enteritis and colitis may each respond to a gluten-free diet. There is also evidence for a causal or exacerbating effect of certain medications.24, 25, 57, 58, 59, 60

Yep, you don't dare suggest a gluten-free diet unless an MC patient also has celiac disease, cause that just wouldn't be right.

All in all, it's a good article, (outside of the fact that it totally misses the most practical way to treat the disease). Obviously, Dr. Pardi is well acquainted with all the official research related to MC, (whether it has any validity or not), but he's not about to do any thinking on his own, (after all, he's part of the Mayo Clinic GI team, first, last, and always, and they're the "experts" - or so they claim).

Tex

[TooManyHats]

Gee, and I thought all the experts were here.

[Bifcus16]

I thought that considering how close he came to suggesting a dietary involvement, that he may well have done some independent thought. The clues are all there, which is better than most articles which don't even mention gluten and suggest 6 weeks of Entocort is a cure. Heck, he even suggests removing drugs or 'other agents eg dairy' that might be causing it. There could be a lot hidden in that 'other agents' phrase.

But that doesn't mean he would be willing to risk his professional standing by going against the grain (boom boom) without strong evidence - and the evidence that a journal would accept just isn't available yet. Or at least I haven't seen it.

I think it is one of the better mainstream medical articles on the condition. It recommends long term Entocort, and it acknowledges that pain can be a symptom. It raises the subject of gluten, so people reading it won't be so shocked when for many the real answer turns out to be avoiding gluten.

Lyn

[TooManyHats]

Aminosalicylates were successful in most patients in a controlled trial,129 but several large retrospective studies reported that less than 50% of patients benefited from these drugs

You mean I'm just incredibly lucky? It did take longer for me to respond to the medication, and also the addition of the supplement for histamine, but I wonder what the relapse rate is after discontinuance of mesalamine vs entocort.

[tex]

I think it is one of the better mainstream medical articles on the condition. It recommends long term Entocort, and it acknowledges that pain can be a symptom. It raises the subject of gluten, so people reading it won't be so shocked when for many the real answer turns out to be avoiding gluten.

I agree that it's definitely the most comprehensive article about MC that I've seen to date, especially from anyone affiliated with a major medical institution, and I have a hunch that you're right - if it weren't for all the "good ol' boys" peering over his shoulder, he probably would have gone a bit further with his personal observations/insight. He may be "chumming" the old fishin' hole, to see if he gets a rise out of any of the lunkers lurking there.

Tex

[tex]

You mean I'm just incredibly lucky? It did take longer for me to respond to the medication, and also the addition of the supplement for histamine, but I wonder what the relapse rate is after discontinuance of mesalamine vs entocort.

Yes, our experience here shows that remission rates for the 5-ASA drugs are much lower than commonly reported in the literature. They're much better as a maintenance treatment, than they are as a therapeutic treatment. They are certainly not a cure, (there is no cure for MC), so if you discontinue taking it, you will relapse, UNLESS your diet has been perfected, and your gut has had time to heal sufficiently.

Tex

[TooManyHats]

I find I have to be much more careful with what I eat than it seems (or at least I interpret) users of Entocort have to be. But that's OK with me. I'd rather know what I can and can't eat even while taking medication.

[sarkin]

Arlene, I was also 'incredibly lucky' with Asacol, years ago. And Tex is right; because I didn't know about diet, I relapsed. I had an atypically long run of luck, but who knows what gluten damage I accumulated in other systems while the gut seemed to be behaving?

I agree with you entirely, I would rather know what I can eat and what I must avoid, and I'd rather choose safely than risk setbacks. It's really liberating, actually. My food preferences and cravings are molehills, compared to the mountain of MC.

I feel lucky that I'm able to make progress with diet alone. Entocort seems like a life-changing help, and though I'm usually anti-Rx, if I couldn't stabilize myself without it, I'd be open to giving it a try.

Very interesting comments on the article, everyone - great discussion, thanks!

Sara

[Gloria]

I find I have to be much more careful with what I eat than it seems (or at least I interpret) users of Entocort have to be.

It depends on the person and how many intolerances they have. I have to be extremely careful about what I eat, too. I can't have any slip-ups without reacting.

Gloria