Aminosalicylate und Steroide in der Behandlung von chronisch entzündlichen Darmerkrankungen - Konsensuspapier der Arbeitsgruppe für chronisch entzündliche Darmerkrankungen der ÖGGH

Zusammenfassung

5-Aminosalicylate (5-ASA) und Steroide gelten als Medikamente der Basistherapie bei Patienten mit chronisch entzündlichen Darmerkrankungen (CED). Während der Stellenwert von 5-ASA in der Therapie des Morbus Crohn (MC) zunehmend diskutiert wird, stellt die Colitis ulcerosa (CU) unverändert ihre Hauptindikation dar. In dieser Indikation spielen sie sowohl in der Akuttherapie eines milden bis moderaten Schubes als auch in der Remissionserhaltung eine wichtige Rolle. Zudem ist die Wirksamkeit von topisch applizierten 5-ASA-Präparaten in der Lokaltherapie von milden bis moderaten Schüben einer Proctitis ulcerosa bzw. linksseitigen Kolitis etabliert und ein additiver Effekt zur oralen Therapie belegt. Der Nutzen von 5-ASA-Präparaten in der Chemoprevention CED-assoziierter kolorektaler Karzinome wird aus retrospektiven Studien vermutet. Steroide stellen die Therapie der ersten Wahl in der Behandlung des moderat bis stark aktiven Schubes sowohl bei MC als auch bei CU dar. Neben wirkungsarmen, topisch wirksamen Steroiden wie Budesonid soll bei mildem bis moderatem Schub eines primär ileozökalen MC mit oder ohne Befall des rechten Kolons der Vorzug gegeben werden, noch vor 5-ASA-Präparaten oder systemisch wirksamen Steroiden. Die Notwendigkeit einer systemischen Steroidtherapie muss als prognostisch ungünstiger Indikator einer CED gesehen werden und soll an den frühzeitigen therapeutischen Einsatz von Immunsuppressiva denken lassen. Eine Dauertherapie mit systemisch wirksamen Steroiden und wohl auch Budesonid muss vermieden werden. Steroide spielen in der Langzeittherapie dieser Erkrankungen keine Rolle. Eine begleitende Osteoporoseprophylaxe mit Calcium und Vitamin D ist parallel zu einer Steroidtherapie durchzuführen. Steroide sind in der Lokaltherapie einer CU 5-ASA-Präparaten unterlegen.

Abstract

5-aminosalicylates (5-ASA) and steroids constitute a cornerstone of medical therapy in patients with inflammatory bowel diseases (IBD). Whereas the efficacy of 5-ASA in Crohn’s disease (CD) is equivocal, ulcerative colitis (UC) is the main indication for this drug. In UC, 5-ASA is effective in the treatment of mild to moderate acute disease and in maintenance of remission. Furthermore, 5-ASA topical therapy is an important treatment option in patients with mild to moderate proctitis and/or left-sided UC and shows additive efficacy to oral therapy. From retrospective data a chemo-preventative activity of long-term 5-ASA therapy in UC is delineated. Steroids are treatment of first choice for moderate to severe cases of CD and UC. Budesonide, a modified steroid with less side effects, plays a major role in the treatment of ileocolonic CD ± involvement of the right colon and is used as treatment of choice in mild-to-moderate cases. In case of acute, severe disease conventional steroids are superior compared to budesonide and therefore budesonide should only be used after considerable improvement of disease activity. The necessity to apply steroids in a given patient represents a negative prognostic indicator for the course of disease and should incite the early introduction of immunosuppressive therapy in this case. Steroids are only effective as short term therapy of IBD and are to be avoided for maintenance treatment. In all cases of steroid therapy an osteoporosis prophylaxis with calcium and vitamin D is recommended. Topical steroid treatment is less effective in left-sided UC compared to 5-ASA.

Schlüsselwörter

Aminosalicylate - Kortikosteroide - Morbus Crohn - Colitis ulcerosa - Inflammation

Key words

5-aminosalicylates - Corticosteroids - Crohn's disease - Ulcerative colitis - Inflammation

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