Evidence-Based Approach to Chronic Antibiotic Refractory Pouchitis: A Review.

BACKGROUND: Chronic antibiotic refractory pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis, characterized by at least 4 weeks of pouchitis symptoms that have not responded to standard antibiotic therapy, presents a therapeutic challenge for patients and healthcare providers.

OBJECTIVE: The aim of this narrative review was to summarize the current evidence regarding management of chronic antibiotic refractory pouchitis.

DATA SOURCES: Studies were identified through search of PubMed database from the National Library of Medicine.

STUDY SELECTION: We included case series, cohort studies, randomized-controlled trials, and systematic reviews with meta-analyses that addressed chronic antibiotic refractory pouchitis management, with prioritization of data published within the last 3-5 years.

INTERVENTION: Studies examining pharmacologic and select non-pharmacologic interventions were included.

MAIN OUTCOME MEASURE: Outcomes measures included clinical, endoscopic, and histologic endpoints.

RESULTS: Mesalamine has demonstrated efficacy in symptom improvement but no improvement in quality of life. Budesonide has demonstrated high rates of clinical remission that have mostly been sustained in a small number of patients. Anti-tumor necrosis factor alpha therapies have demonstrated efficacy in reaching clinical and even endoscopic endpoints, although rates of treatment discontinuation were not insignificant. Limited evidence is encouraging for use of ustekinumab in achieving clinical response. Data for vedolizumab are favorable across clinical, endoscopic, and histologic endpoints, including one of the only randomized, placebo-controlled trials. Non-medication therapies including hyperbaric oxygen therapy and fecal microbiota transplant have undergone limited evaluation and concerns about ultimate accessibility of these therapies remain.

LIMITATIONS: Overall, studies assessing therapeutic options for chronic antibiotic refractory pouchitis are mostly limited to case series and retrospective studies with small sample sizes.

CONCLUSIONS: Biologic therapies have demonstrated efficacy in the management of chronic antibiotic refractory pouchitis and offer a steroid-sparing option for refractory disease. Non-pharmacologic therapies, including hyperbaric oxygen and fecal microbiota transplant, require further exploration. See video.