Evaluation of the Efficacy of Local Budesonide Treatment in Children with Crohn's Disease Located in the Esophagus And/or Stomach And/or Duodenum

Overview

Crohn's disease (CD) is an inflammatory bowel disease characterized by chronic symptoms that include periods of exacerbation and remission. The exact cause of CD is not fully understood, but it is believed to result from a combination of genetic predispositions, immunological disorders, and environmental factors. The incidence of CD is on the rise, particularly among children, with estimates suggesting that it affects 1 in 500 people in Western Europe and North America. Notably, one in four patients diagnosed with CD are children. The inflammatory changes associated with CD can affect the entire thickness of the gastrointestinal wall and can occur anywhere along the gastrointestinal tract, from the mouth to the anus. Persistent inflammation in the gastrointestinal tract increases the risk of cancer, which is already heightened in patients with CD. In the pediatric population, inflammation in the esophagus, stomach, and duodenum is present in about 30% of cases and is associated with a poorer prognosis. Another factor linked to a worse prognosis is the age at diagnosis; younger patients tend to have a more severe disease course. Therefore, all children with CD generally experience a worse prognosis compared to adults. The treatment of CD is life-lasting and often challenging. It includes dietary modifications, pharmacological interventions, and sometimes surgical procedures, depending on the disease's activity and the location of the inflammation. The pharmacological treatment typically involves several types of medications: 5-ASA preparations, immunomodulatory drugs, biological drugs and local treatments such as suppositories, enemas and prolonged-release capsules. The most effective treatment approaches combine both systemic and local medications targeted at the affected areas of the intestine. In local treatment for CD, budesonide plays a crucial role. This corticosteroid has a strong anti-inflammatory effect and is characterized by low bioavailability, with 90% of the drug metabolized in the liver. Consequently, only 10% reaches the systemic circulation, minimizing the potential for adverse effects. Currently, budesonide is used to treat inflammatory changes in the distal small intestine (via sustained-release or enteric-coated capsules), rectum, and sigmoid colon (as rectal foam), or in the large intestine (with multimatrix tablets). Unfortunately, there is no local treatment available for patients with CD who have inflammation in the esophagus, stomach, or duodenum. Recommendations often suggest the use of antacids, such as proton pump inhibitors, which typically alleviate symptoms but do not promote remission of the inflammation. Given this gap in treatment, it has been hypothesized that adding locally acting budesonide to systemic therapy could be effective for children with inflammatory changes in the esophagus, stomach, and/or duodenum associated with CD. The aim of this study is to assess the efficacy of locally applied budesonide in treating these specific inflammatory changes in pediatric patients with Crohn's disease.