Immunsuppressiva in der Therapie chronisch entzündlicher Darmerkrankungen

Zusammenfassung

Eine Therapie mit Azathioprin (AZA) oder 6-Mercaptopurin (6-MP) stellt heute in der Behandlung des Morbus Crohn die erste Wahl einer immunsuppressiven Therapie dar. Indikation ist oft der zweite steroidbedürftige Krankheitsschub innerhalb eines Jahres. Die optimale Dosierung beträgt bei den meisten Patienten 2,5 mg/kg KG und das Eintreten der vollen Wirkung ist manchmal erst nach 6 - 7 Monaten zu erwarten. Intramuskulär appliziertes Methotrexat (MTX) gilt als Mittel zweiter Wahl und die Wirksamkeit ist auf den Morbus Crohn beschränkt. Der Eintritt der Wirkung erfolgt früher als unter Therapie mit AZA. Studien zur Wirksamkeit oraler MTX-Gabe liegen zur zeit nicht vor. Cyclosporin A ist das Mittel der Wahl bei steroidrefraktärer schwerer akuter Colitis ulcerosa, wenn keine OP sinnvoll erscheint. Wahrscheinlich ist eine Dosierung von 2 mg/kg intravenös ausreichend. Bei Ansprechen ist eine Rezidivprophylaxe mit AZA umgehend einzuleiten. Weitere Einsatzgebiete für Cyclosporin A sind schwere extraintestinale Manifestationen chronisch entzündlicher Darmerkrankungen (CED). Zu anderen Immunsuppressiva wie Mycophenolat liegen keine ausreichend kontrollierten Daten vor bzw. ist das Toxizitätsprofil ungünstig (6-Thioguanin). Das Malignomrisiko unter immunsuppressiver Therapie bei CED dürfte nur unwesentlich gesteigert sein. Vor allem AZA und 6-MP können mit relativ hoher Sicherheit für Kind und Mutter in der Schwangerschaft gegeben werden, wenn auch die Indikation stets individuell in Abhängigkeit von der Krankheitsaktivität und dem zu erwartenden Krankheitsverlauf zu stellen ist.

Abstract

Azathioprine (AZA) or 6-mercaptopurine (6-MP) are the immunosuppressive drugs of choice in the treatment of inflammatory bowel disorders (IBD). Optimal dosage for AZA is around 2.5 mg/kg body weight and induction of remission by these drugs may take 6 - 7 months. Intramuscularly applied Methotrexate (MTX) is the second choice, while its efficacy starts earlier than that of AZA; studies assessing oral low-dose MTX treatment are lacking. Cyclosporin is the standard treatment in case of steroid-refractory severe ulcerative colitis. This drug may also be used in patients with severe extraintestinal manifestations of IBD. Regarding other immunosuppressive drugs such as mycophenolic acid or 6-thioguanine respective controlled clinical study data are not available. The risk of malignancy using immunosuppressive drugs such as AZA is low and furthermore, especially AZA and 6-MP can be used rather safely during pregnancy.

Schlüsselwörter

Referenzen

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