Published in BMJ OPEN Gastroenterology, September 2021
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Exclusive enteral nutrition (EEN) is a treatment option for adults with Crohn’s disease, though it is often not used as a first-line treatment. The authors of this narrative review (New South Wales, Australia) sought to examine the evidence for EEN therapy in the management of adult patients with Crohn’s disease (CD) and questioned if EEN should be a first-line option.
The review firstly looks at the proposed mechanism of the action of EEN, covering improvement in nutritional deficiencies, microbiota changes and anti-inflammatory effects. It then reviews EN formulations and highlights how the formulations can vary considerably, with the use of elemental, semi-elemental and polymeric feeds. A Cochrane meta-analysis (2018) comparing elemental to non-elemental EEN found similar clinical remission rates. The use of corticosteroids is discussed and concludes that EEN has similar remission rates as corticosteroids, but avoids the metabolic and systemic side-effects. In terms of surgery, which is often required (80% of adults within 20 years of diagnosis), EEN has been shown to avoid the need for surgery in a sub-set of patients and improve outcomes in those who go to require surgery.
In terms of limitations, the real challenge is compliance and typically there are high non-compliance rates in adults. This can be for a variety of reasons including poor palatability, lack of variety, missing the social aspect of food, lack of motivation and lack of acceptance of a feeding tube. In general, compliance rates have been reported of 50-80%, generally reducing with longer duration of therapy. Some studies have shown that patient education and increased out-patient support can help improve overall compliance.
Overall the authors conclude that ‘EEN has also shown promise in the management of adult patients with CD’. There are benefits to EEN, but larger, higher quality studies are needed to confirm these findings and ideally an infrastructure is required to support patients and adherence to the feeding regimen.