Medical therapy

The observation that the majority of patients with indeterminate colitis over time are reclassi-fied as ulcerative colitis or Crohn's disease makes it difficult to know whether indeterminate colitis represents a separate form of IBD. Perhaps because of the small number of patients with indeterminate colitis, the response to various drug regimens in this population has not been specifically addressed.7 In our program the choice of therapeutic intervention is selected depending on the severity of symptoms, extent and severity of endoscopic and histological findings and laboratory parameters23 (Table 24.4). For most patients, drug therapy is similar to that indicated for patients with ulcerative colitis of comparable extent and severity. These include 5-aminosalicylic acid (5-ASA) preparations for mild disease and corticosteroids and immunomodulatory therapy for moderate and severe disease. However, we are more likely to use metronidazole in this population, especially where there is extensive focal colitis or those 'favoring' Crohn's disease. Immunomodulatory agents, such as azathioprine or 6-mercaptop-urine, are used in approximately 60% of our pediatric population with IBD, owing to the presence of steroid dependency, resistance or toxic-ity.24

Many large series involving clinical trials of adult patients with IBD have included small numbers of patients with indeterminate colitis, although they have not specifically addressed the treatment of indeterminate colitis.7 The response of adult patients with refractory ulcerative colitis and indeterminate colitis appears to show similar improvement to azathioprine/6-mercaptopurine and cyclo-sporin as well as newer immunomodulatory agents such tacrolimus and thalidomide.25-27 The role of inflix-imab in indeterminate colitis is as yet to be determined. However, favorable outcomes in pediatric patients with ulcerative colitis suggest that it could be considered in patients with indeterminate colitis who are not responding to conventional medications.28

Table 24.4 Medical approach to the pediatric patient with indeterminate colitis

5-Aminosalicylic acid preparations for mild disease

Corticosteroids (moderate-to-severe disease severity)

Metronidazole if histology favors Crohn's disease

Azathioprine (AZA) or 6-mercaptopurine (6-MP)

Consider measuring red blood cell 6-thioguanine levels to reduce the risk of toxicity if increasing the dose in refractory patients

Change to AZA from 6-MP (or vice versa) for non-hypersensitivity side-effects (e.g. rash, arthralgia, headache) Methotrexate (parenterally) if intolerant or refractory to AZA/6-MP Cyclosporin intravenously or micro-emulsified oral formulation Tacrolimus (0.1-0.15mg/kg twice a day); monitor blood level Thalidomide (50-100mg/day in older children and adolescents) Remicade (at conventional dosing)

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