What’s New


NICE Publishes New Guideline on Crohn’s Disease NICE has published guidance on the role of new and established treatments for the management of Crohn’s disease in adults and children.


Crohn's disease is a chronic inflammatory condition that mainly affects the gastrointestinal tract (gut). It can develop at any age but most commonly starts between the ages of 15 and 30, with around a third of patients diagnosed before the age of 21. The disease affects slightly more women than men. Its cause is unknown, but it is around twice as common in smokers. There are currently around 115,000 people living with Crohn's disease in the UK and between 3000 and 6000 new cases are diagnosed each year. An estimated five per cent of patients have severe disease, but the proportion of people with moderate Crohn's disease is unclear. The condition can lead to delay of growth and puberty in children, as well as affecting fertility and sexual relationships in adults. Common symptoms of Crohn's disease


include: • Recurring diarrhoea • Abdominal pain and cramping (the pain is often worse after eating)


• Blood and mucus in faeces • Extreme tiredness • Weight loss There may be long periods that last for weeks or months where there are mild or no symptoms,


followed by periods where symptoms are particularly upsetting, which are known as flare-ups. In the last decade, there have been a number


of new drugs licensed for the condition. Glucocorticosteroids can be offered to induce remission in people with Crohn's disease and azathioprine or mercaptopurine can be offered as maintenance treatment. The new guidance covers the use of these drugs in the care pathway for Crohn's disease. Aimed at all healthcare professionals involved


in the management of Crohn's disease, recommendations include: • Offer monotherapy with a conventional glucocorticosteroid


methylprednisolone or


(prednisolone, intravenous


hydrocortisone) to induce remission in people with a first presentation or a single inflammatory exacerbation of Crohn's disease in a 12 month period.


• Discuss with people with Crohn's disease, and/or their carer if appropriate, options for managing their disease when they are in remission, including both no treatment and treatment. The discussion should include the risk of inflammatory exacerbations (with and without drug treatment) and the potential side


effects of drug treatment. Record the person's views in their notes.


• Offer azathioprine or mercaptopurine as monotherapy to maintain remission when previously used with a conventional glucocorticosteroid or budesonide to induce remission.


• Consider surgery as an alternative to medical treatment early in the course of the disease for people whose disease is limited to the distal ileum (small intestine), taking into account the following:


- benefits and risks of medical treatment and surgery


- risk of recurrence after surgery - individual preferences and any personal or cultural considerations.


Record the person's views in their notes. • Offer adults, children and young people, and/or their parents or carers, age-appropriate multidisciplinary support to deal with any concerns about the disease and its treatment, including concerns about body image, living with a chronic illness, and attending school and higher education.


The new NICE clinical guideline on Crohn's disease can be found at: www.nice.org.uk/CG152


Multivitamin use Among Middle-aged, Older Men Results in Modest


Reduction in Cancer In a randomised trial that included nearly 15,000 male physicians, long-term daily multivitamin use resulted in a modest but statistically significant reduction in cancer after more than a decade of treatment and follow-up, according to a study appearing in JAMA. The study is being published early online to coincide with its presentation at the Annual American Association for Cancer Research Frontiers in Cancer Prevention Research meeting.


J. Michael Gaziano, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, (and also Contributing Editor, JAMA), and colleagues analysed data from the Physicians' Health Study (PHS) II, the only large-scale, randomised, double-blind, placebo-controlled trial testing the long-term effects of a common multivitamin in the prevention of chronic disease. The trial includes 14,641 male U.S. physicians, initially age 50 years or older, including 1,312 men with a history of cancer at randomization, who were enrolled in a multivitamin study that began in 1997 with treatment and follow- up through June 1, 2011. Participants received a daily multivitamin or equivalent placebo. The primary measured outcome for the study was total cancer (excluding nonmelanoma skin cancer), with prostate, colorectal, and other site-specific cancers among the secondary end points. PHS II participants were followed for an average


of 11.2 years. During multivitamin treatment, there were 2,669 confirmed cases of cancer, including 1,373 cases of prostate cancer and 210 cases of colorectal cancer, with some men experiencing multiple events. A total of 2,757 (18.8 percent) men died during follow-up, including 859 (5.9 percent) due to cancer. Analysis of the data indicated that


3 BAPEN In Touch No.67 November 2012


men taking a multivitamin had a modest eight per cent reduction in total cancer incidence. Men taking a multivitamin had a similar reduction in total epithelial cell cancer. Approximately half of all incident cancers were prostate cancer, many of which were early stage. The researchers found no effect of a multivitamin on prostate cancer, whereas a multivitamin significantly reduced the risk of total cancer excluding prostate cancer. There were no statistically significant reductions in individual site- specific cancers, including colorectal, lung, and bladder cancer, or in cancer mortality. Daily multivitamin use was also associated with a


reduction in total cancer among the 1,312 men with a baseline history of cancer, but this result did not significantly differ from that observed among 13,329 men initially without cancer. The researchers note that total cancer rates in


their trial were likely to have been influenced by the increased surveillance for prostate-specific antigen (PSA) and subsequent diagnoses of prostate cancer during PHS II follow-up starting in the late 1990s. "Approximately half of all confirmed cancers in PHS II were prostate cancer, of which the vast majority were earlier stage, lower grade prostate cancer with high survival rates. The significant reduction in total cancer


minus prostate cancer suggests that daily multivitamin use may have a greater benefit on more clinically relevant cancer diagnoses." The authors add that although numerous


individual vitamins and minerals contained in the PHS II multivitamin study have postulated chemopreventive roles, it is difficult to definitively identify any single mechanism of effect through which individual or multiple components of their tested multivitamin may have reduced cancer risk. "The reduction in total cancer risk in PHS II argues that the broader combination of low-dose vitamins and minerals contained in the PHS II multivitamin, rather than an emphasis on previously tested high-dose vitamins and mineral trials, may be paramount for cancer prevention. … The role of a food-focused cancer prevention strategy such as targeted fruit and vegetable intake remains promising but unproven given the inconsistent epidemiologic evidence and lack of definitive trial data." "Although the main reason to take multivitamins


is to prevent nutritional deficiency, these data provide support for the potential use of multivitamin supplements in the prevention of cancer in middle- aged and older men," the researchers conclude. doi:10.1001/jama.2012.14641


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