BNF for Children 2011-2012

BNFC 2011–2012 1.5.1 Aminosalicylates 49NICE guidanceInfliximab for Crohn’s disease (May 2010)In children over 6 years of age, infliximab is recommendedfor the treatment of severe active Crohn’sdisease that has not responded to conventionaltherapy (including corticosteroids, other drugsaffecting the immune response, and primary nutritiontherapy) or when conventional therapy cannotbe used because of intolerance or contra-indications.Infliximab should be given as a planned course oftreatment for 12 months or until treatment failure,whichever is shorter. Treatment should be continuedbeyond 12 months only if there is evidence of activedisease—in these cases the need for treatmentshould be reviewed at least annually. If the diseaserelapses after stopping treatment, infliximab can berestarted [but see Hypersensitivity Reactions underInfliximab, p. 55].NICE guidanceInfliximab for subacute manifestations ofulcerative colitis (April 2008)Infliximab is not recommended for the treatment ofsubacute manifestations of moderate to severeactive ulcerative colitis that would normally be managedin an outpatient setting.Maintenance of remission of acute ulcerativecolitis and Crohn’s disease Children should beadvised not to smoke because smoking increases therisk of relapse in Crohn’s disease. Smoking cessation(section 4.10.2) should be encouraged when necessary.Aminosalicylates are efficacious in the maintenance ofremission of ulcerative colitis, but there is no evidenceof efficacy in the maintenance of remission of Crohn’sdisease. Corticosteroids are not suitable for maintenancetreatment because of their side-effects. In resistantor frequently relapsing cases either azathioprine(section 1.5.3) or mercaptopurine (section 1.5.3) maybe helpful. Methotrexate (section 1.5.3) is used inCrohn’s disease when azathioprine or mercaptopurineare ineffective or not tolerated. Infliximab (p. 55) canbe used for maintenance therapy in Crohn’s disease orulcerative colitis in children who respond to the initialinduction course of this drug. There are concerns aboutthe long-term safety of infliximab in children.Fistulating Crohn’s disease Treatment may not benecessary for simple, asymptomatic perianal fistulas.Metronidazole (section 5.1.11) or ciprofloxacin (section5.1.12) may be beneficial for the treatment offistulating Crohn’s disease [both unlicensed for thisindication]. Metronidazole by mouth is used at a doseof 7.5 mg/kg 3 times daily, usually for 1 month; it shouldnot be used for longer than 3 months because of concernsabout peripheral neuropathy. Ciprofloxacin bymouth is given at a dose of 5 mg/kg twice daily. Otherantibacterials should be given if specifically indicated(e.g. sepsis associated with fistulas and perianal disease)and for managing bacterial overgrowth in the smallbowel. Fistulas may also require surgical explorationand local drainage.Either azathioprine or mercaptopurine is used as asecond-line treatment for fistulating Crohn’s disease andcontinued for maintenance. Infliximab is used for fistulatingCrohn’s disease refractory to conventionaltreatments; maintenance therapy with infliximab shouldbe considered for patients who respond to the initialinduction course.Adjunctive treatment of inflammatory bowel diseaseDue attention should be paid to diet; high-fibre orlow-residue diets should be used as appropriate.Antimotility drugs such as codeine phosphate and loperamide,and antispasmodic drugs may precipitate paralyticileus and megacolon in active ulcerative colitis;treatment of the inflammation is more logical. Laxativesmay be required in proctitis. Diarrhoea resulting fromthe loss of bile-salt absorption (e.g. in terminal ilealdisease or bowel resection) may improve with colestyramine(section 1.9.2), which binds bile salts.Irritable bowel syndromeIrritable bowel syndrome can present with pain, constipation,or diarrhoea. Some children have importantpsychological aggravating factors which respond toreassurance. The fibre intake of children with irritablebowel syndrome should be reviewed. If an increase indietary fibre is required, soluble fibre (e.g. oats, ispaghulahusk, or sterculia) is recommended; insolublefibre (e.g. bran) should be avoided. A laxative (section1.6) can be used to treat constipation. An osmoticlaxative, such as a macrogol, is preferred; lactulosemay cause bloating. Loperamide (section 1.4.2) mayrelieve diarrhoea and antispasmodic drugs (section 1.2)may relieve pain. Opioids with a central action, such ascodeine, are better avoided because of the risk of dependence.Clostridium difficile infectionClostridium difficile infection is caused by colonisationof the colon with Clostridium difficile and production oftoxin. It often follows antibiotic therapy and is usually ofacute onset, but may become chronic. It is a particularhazard of ampicillin, amoxicillin, co-amoxiclav, secondandthird-generation cephalosporins, clindamycin, andquinolones, but few antibacterials are free of this sideeffect.Oral metronidazole (section 5.1.11) or oralvancomycin (section 5.1.7) are used as specific treatment;vancomycin may be preferred for very sickpatients. Metronidazole can be given by intravenousinfusion if oral treatment is inappropriate.Malabsorption syndromesIndividual conditions need specific management andalso general nutritional consideration. Coeliac disease(gluten enteropathy) usually needs a gluten-free diet(Appendix 2) and pancreatic insufficiency needs pancreatinsupplements (section 1.9.4).For further information on foods for special diets(ACBS), see Appendix 2.1.5.1 AminosalicylatesSulfasalazine is a combination of 5-aminosalicylic acid(‘5-ASA’) and sulfapyridine; sulfapyridine acts only as acarrier to the colonic site of action but still causes sideeffects.In the newer aminosalicylates, mesalazine (5-aminosalicylic acid), balsalazide (a prodrug of 5-amino-1 Gastro-intestinal system