From the AGA Journals

Budesonide topped placebo for treating lymphocytic colitis



Among patients with lymphocytic colitis, 8 weeks of oral budesonide therapy was associated with significantly higher rates of clinical and histologic remission versus placebo in a multicenter, double-blind clinical trial.

Fully 79% of patients achieved clinical remission with budesonide, compared with only 42% of patients in the placebo arm (P = .01), reported Stephan Miehlke, MD, of the Center for Digestive Diseases in Hamburg, Germany, and his associates. A third group of patients received oral mesalazine therapy, which induced clinical remission in 68% of cases (P = .09). Budesonide also induced histologic remission significantly more often (68%) than did mesalazine (26%; P = .02) or placebo (21%; P = .008).

“The study population was not large, but the trial was adequately powered,” the researchers wrote. The report was published online in Gastroenterology. “These results confirm the efficacy of budesonide for the induction of remission in active lymphocytic colitis and are consistent with expert recommendations for its use as first-line therapy.”

Lymphocytic colitis is a subtype of microscopic colitis that is characterized by an increase in intraepithelial lymphocytes. This condition has substantial negative effects on quality of life – the most common symptom is chronic diarrhea, and some patients also experience fecal incontinence and abdominal pain. Expert guidelines recommend first-line treatment with budesonide and second-line treatment with mesalazine, but evidence supporting either recommendation is sparse and low-quality, the investigators wrote.

For the study, they compared 8 weeks of treatment with pH-modified release oral budesonide granules (9 mg once daily), oral mesalazine granules (3 g once daily) or placebo in 57 patients (19 per arm) with histologically confirmed, newly diagnosed or relapsed lymphocytic colitis. All patients had at least a 12-week history of watery, nonbloody diarrhea, no other documented diarrheal conditions, and no recent history of antidiarrheal therapy. Nearly three-quarters were female and the mean age was 59 years. The primary endpoint was clinical remission, defined as no more than 21 stools in the 7 days before week 8, including no more than 6 watery stools.

After 8 weeks of double-blinded treatment, all clinically remitted patients stopped treatment and were followed for another 16 weeks. Those who were not in remission or who relapsed were offered 4 weeks of open-label budesonide therapy, which led to clinical remission in 88% of cases, the researchers said. “This study confirms that budesonide is effective for the induction of remission in active lymphocytic colitis,” they concluded. “Strikingly, a substantial improvement in symptoms, including a profound reduction in the number of watery stools, was seen within a median of 3 days after starting budesonide therapy.”

Serious adverse events were uncommon in all three groups, and each arm had a similar rate of adverse events considered secondary to treatment. In the budesonide group, these included one case each of weight gain, transient ischemic attack, and affective disturbance with sleep disorder. In the mesalazine group, three patients developed acute pancreatitis, increased hepatic enzymes, or dizziness. Eleven percent of budesonide recipients and 16% of mesalazine recipients stopped treatment because of adverse events. “No patient in any group had a clinically significant shift in cortisol level between baseline and week 8 that was considered related to the study drug,” the investigators said. “Other changes in laboratory parameters were not considered clinically relevant in any treatment group.”

The study was funded by Dr. Falk Pharma GmbH, Freiburg, Germany. Dr. Miehlke and two coauthors received speaker fees from Dr. Falk Pharma. Dr. Miehlke and one coauthor received consultancy fees from Tillots. One coauthor received speaker fees, has been a member of the advisory board, and has received grants from Tillots.

SOURCE: Miehlke S et al. Gastroenterology. 2018 Sep 6. doi: 10.1053/j.gastro.2018.08.042.

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