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Dear Sir, Treatment of paediatric ulcerative colitis (UC) unresponsive to conventional treatment constitutes a challenge. According to the classical step-up strategy, flare-ups that do not respond to oral and/or topical 5-ASA, are tributary of systemic steroids. Although treatment with oral or intravenous corticosteroids is effective in most patients, severe cases of steroid-refractory pancolitis will need colectomy even at diagnosis.1 Wide experience with cyclosporine A has shown its efficacy in preventing emergency colectomy, although its effect seems to be poorer in the long-term, most of these patients needing colectomy within a few months or years period. Recent experience with the anti-TNF-α monoclonal chimeric antibody (Infliximab) has shown also its efficacy as rescue therapy in preventing colectomy in patients with fulminant paediatric UC.2 On the other hand, a significant proportion of the paediatric UC patients who respond to steroid treatment will develop steroid-resistance (29%) or steroid-dependence (14%) during the follow-up.3 Early introduction of immunomodulators (azathioprine, 6-mercaptopurine) have proved to be steroid-sparing and to heal the mucosa as well.4 Nevertheless, there are still a group of patients in whom …

Background: Tumour necrosis factor alpha (TNF-a) plays an important role in malnutrition and growth retardation in paediatric inflammatory bowel disease (IBD) due to perpetuation of chronic inflammation. One of the objectives in the management of these patients should be to optimize their growth, which may be compromised due to uncontrolled disease and the effect of steroids. We aimed to study anti-TNF treatment effect on nutritional recovery in paediatric IBD, in relation to their efficacy in clinical response, both in shortand medium-term. Methods: Retrospective analysis of our paediatric IBD patients treated with anti-TNF between January 2002 and December 2010. We evaluated clinical response as defined by changes in activity scores (Paediatric Crohn’s Disease Activity Index [PCDAI] and Paediatric Ulcerative Colitis Activity Index [PUCAI]) at 2 and 8 weeks, 6 months and 1 year after its initiation. Changes in anthropometric measures (height and weight for age and body mass index [BMI]) and biochemical modifications (ESR, CRP, haemoglobin, platelets and albumin) were evaluated at 6 and 12 months. Results: 54 patients (34 boys) received anti-TNF (44 CD, 8 UC, 2 IBDU). Age at diagnosis: 11 years 5 months. Mean time from diagnosis to anti-TNF treatment: 17 months (range 0 121). Mean age at first infusion 13 years (1.1 17.3). Mean followup 35 months and mean number of infusions per patient 17. Forty-one patients received infliximab (IFX), 21 adalimumab (ADA) and 1 certolizumab pegol. Thirty-one patients (63%) had not previously received steroids. Mean basal PCDAI and PUCAI: 28.6 (2.5 62) and 39 (27 55) respectively. Clinical response was achieved in 47 cases (87%). Remission rate was 74.2% at 2 weeks, 87.7% at 8 weeks, 90% at 6 months, and 90.6% at 12 months. Seven patients experienced a relapse at some point of the follow-up. Median steroid-free time from the beginning of anti-TNF was 25.9 months (1 76). Mean BMI prior to treatment was 17, z-score 1.04 ( 4.2, +1.64). We observed improvement of anthropometry, with a mean BMI of 19.2 [z-score 0.27 ( 2.3, +1.78)] after 12 months. Biochemical parameters improvement was also observed at 6 and 12 months, with significant reduction of inflammatory markers and increase in haemoglobin and albumin levels. Conclusions: Anti-TNF treatment shows high efficacy in obtaining and maintaining clinical remission in paediatric IBD. Furthermore it has a positive impact on the nutritional status. This effect is parallel to the decrease in disease activity.

Results: two weeks later, we started azathioprine as maintenance therapy. Oral prednisone was tapered after 2 months, instead cyclosporine was tapered after 4 months and the patient was maintained on oral 5-ASA and azathioprine 2mg/kg/day. Five years have elapsed and up to date MS and UC are well controlled by azathioprine and she has had no recurrence of both diseases confirmed by MRI and colonoscopy respectively. The patient EDSS still remains stable on 6.5 but she has regained urinary control. Conclusion: Patients with IBD have an increased risk for developing MS. In our patient MS preceded the development of UC by approximately 9 years. The progressive course of MS subsequently complicated with severe UC, shows that probably there are common genetic or environmental factors contributing to the development of these diseases, in their heterogeneous phenotypes, that have not been identified yet.