肠内营养联合雷公藤多甙诱导克罗恩病缓解的研究

Therapeutic effects of combined enteral nutrition with Tripterygium Wilfordii Polyglycosidium in remission induction of active adult Crohn＇s disease

目的探讨联合应用肠内营养和雷公藤多甙在诱导成人活动期克罗恩病缓解中的治疗价值。方法回顾性分析2001年3月至2008年9月接受肠内营养联合雷公藤多甙治疗（治疗组，n=42）或单用雷公藤多甙（对照组，n=20）治疗的62例活动期克罗恩病患者的临床资料。所有患者满足150〈克罗恩病病变活动度评分（CDAI）〈450。对照组给予口服雷公藤多甙片（1．0～1．5mg·kg^-1·d^-1），并进普通饮食。治疗组在口服药物同时，给予管饲全肠内营养支持。比较两组在治疗4周和12周时临床有效率（CDAI下降〉70）和缓解率（CDAI绝对值〈150）的差异，并比较两组治疗不同时间点（治疗前、治疗4周、12周）CDAI、C反应蛋白水平和红细胞沉降率等病变活动度指标及体质指数、血清白蛋白、血红蛋白等营养学指标的变化。部分患者比较内镜下病变活动度的变化。结果治疗组治疗4周时临床有效率和缓解率均显著高于对照组（78．6％vs．40．0％，P=0．003；69．1％郴．30．0％，P=0．004），治疗12周时治疗组临床有效率显著高于对照组（90．5％vs65．0％，P=0．014）。治疗12周时治疗组临床缓解率亦较高，但两组差异无统计学意义（76．2％vs55．0％，P=0．091）。治疗4周时治疗组白蛋白、前白蛋白、转铁蛋白水平均高于对照组（P〈0．05）；而12周时后治疗组的BMI、白蛋白、前白蛋白、转铁蛋白和血红蛋白水平亦均高于对照组（P〈0．05）。治疗组在治疗4周及12周营养学指标均较治疗前显著改善，而雷公藤单药治疗对改善营养学指标作用不大。结论肠内营养联合雷公藤多甙治疗可使活动期克罗恩病获得有效缓解，在改善患者的营养状态的同时可避免激素治疗的副作用。

Objective To investigate the potential role of enteral nutrition （EN） combined with Tripterygium Wilfordii Polyglycosidium （TWP） for remission induction of active adult Crohn＇s disease （CD）. Methods Clinical data of 62 adult patients with active CD treated with EN and TWP in combination （n = 42） or TWP alone （n = 20） from March 2001 to September 2008 were retrospectively analyzed. All the patients had a Crohn＇s Disease Activity Index （CDAI） 〉 150 and 〈450. In TWP group, subjects received TWP tablets （ 1.0 - 1.5mg·kg^-1·d^-1） with uncontrolled diets; while in the group of combination therapy, the patients were given total enteral nutrition （TEN） through tube feeding in addition to TWP tablets. Clinical response was defined by a decrease of at least 70 points in the CDAI from baseline after treatment, and clinical remission was defined as the absolute value of CDAI （less than 150）. Patients＇ nutritional and disease activity index, such as CDAI score, C-reactive protein （CRP） and erythrocyte sedimentation rate （ESR） , were determined at 0, 4, and 12 weeks after treatment. Results The ratio of clinical response （ 78.6% vs. 40. 0% , P = 0. 003 ） and clinical remission （ 69. 1% vs. 30. 0% , P = 0. 004） were both significantly higher in the combined treatment group than in those the TWP group at week 4. At week 12, the clinical response ratio was significantly higher in the combined treatment group （90. 5% vs. 65.0% , P =0. 014） ; the remission ratio was also higher in the combined treatment group （76.2% vs. 55.0%, P =0. 091 ）. The nutritional parameters improved from baseline at week 4 and 12 in the combined treatment group but not in TWP group. At week 4, blood albumin, prealbumin, and transfervin levels was higher in the combined treatment group than those in TWP group （ P 〈 0. 05 ） ; at week 12, patients in combined treatment group also had significantly higher body mass index （BMI）, blood albumin, prealbumin, transferrin and hemoglobin levels （ P 〈 0. 05 ）. Conclusions Treatment with enteral nutrition and TWP in combination are superior to TWP alone for induction of clinical response and remission in adult Crohn＇s Disease. This strategy also improves patient＇s nutritional status and avoids the adverse effects of traditional therapy.