Partial Enteral Nutrition
Partial Enteral Nutrition uses a combination of liquid nutrition and solid foods.
Partial Enteral Nutrition (PEN) involves consuming a percentage of daily calories (35-50%) from liquid nutrition and completing the remainder with solid foods. It is generally used alongside medications to help maintain remission or before and after surgery to optimize nutrition.
PEN to Induce Remission
Partial Enteral Nutrition when combined with a standard diet has not been shown to be effective in inducing remission.1,2 However, using PEN as part of the Crohn’s Disease Exclusion Diet (CDED) has been shown to be effective in inducing remission in pediatric3, 4, 5 and adult Crohn’s disease6 at similar rates to Exclusive Enteral Nutrition (EEN). CDED plus PEN is therefore included as an alternative to EEN to induce remission in some guidelines.7
PEN in combination with anti-TNF medication has shown an increased likelihood of achieving remission compared to those not receiving PEN.8
PEN to Maintain Remission
Partial enteral nutrition in combination with medications is a promising nutritional option to help maintain remission in Crohn’s disease.
PEN in Combination with Biologics
Partial enteral nutrition can be especially beneficial alongside biologic medications. Biologics carry a risk of loss of response. Loss of response occurs when a specific treatment stops working over time. Although more research is needed, the use of PEN alongside biologics may reduce the loss of response to biologics.
In patients experiencing loss of response to an anti-TNF medication, infliximab, PEN combined with dose escalation was compared to dose escalation alone. At interim analysis, the study was halted early, given the clear benefit of PEN combined with dose escalation1
A new clinical trial, BIOPIC (BIOlogics and Partial enteral nutrition), in adults with active ileocolonic Crohn’s disease is evaluating the use of PEN given as fifty percent of calories in combination with biologics.
PEN and Surgery
- Johnson T, Macdonald S, Hill SM, Thomas A, Murphy MS. Treatment of active Crohn’s disease in children using partial enteral nutrition with liquid formula: a randomised controlled trial. Gut. (2006) 55:356–61. 10.1136/gut.2004.062554
- Lee D, Baldassano RN, Otley AR, et al. Comparative Effectiveness of Nutritional and Biological Therapy in North American Children with Active Crohn's Disease. Inflamm Bowel Dis. 2015;21(8):1786-1793. doi:10.1097/MIB.0000000000000426
- Sigall-Boneh R, Pfeffer-Gik T, Segal I, Zangen T, Boaz M, Levine A. Partial enteral nutrition with a Crohn’s disease exclusion diet is effective for induction of remission in children and young adults with Crohn’s disease. Inflamm Bowel Dis. 2014;20(8):1353-1360. doi:10.1097/MIB.0000000000000110
- Levine A, Wine E, Assa A, et al. Crohn's Disease Exclusion Diet Plus Partial Enteral Nutrition Induces Sustained Remission in a Randomized Controlled Trial. Gastroenterology. 2019;157(2):440-450.e8. doi:10.1053/j.gastro.2019.04.021
- Urlep D, Benedik E, Brecelj J, Orel R. Partial enteral nutrition induces clinical and endoscopic remission in active pediatric Crohn's disease: results of a prospective cohort study. Eur J Pediatr. 2020;179(3):431-438. doi:10.1007/s00431-019-03520-7
- Yanai H, Levine A, Hirsch A, et al. The Crohn's disease exclusion diet for induction and maintenance of remission in adults with mild-to-moderate Crohn's disease (CDED-AD): an open-label, pilot, randomised trial. Lancet Gastroenterol Hepatol. 2022;7(1):49-59. doi:10.1016/S2468-1253(21)00299-5
- Bischoff SC, Bager P, Escher J, et al. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr. 2023;42(3):352-379. doi:10.1016/j.clnu.2022.12.004
- Hirai F., Takeda T., Takada Y., Kishi M., Beppu T., Takatsu N., Miyaoka M., Hisabe T., Yao K., Ueki T. Efficacy of enteral nutrition in patients with Crohn’s disease on maintenance anti-TNF-alpha antibody therapy: A meta-analysis. J. Gastroenterol. 2020;55:133–141. doi: 10.1007/s00535-019-01634-1
- Verma S, Kirkwood B, Brown S, Giaffer MH. Oral nutritional supplementation is effective in the maintenance of remission in Crohn's disease. Dig Liver Dis. 2000;32(9):769-774. doi:10.1016/s1590-8658(00)80353-9
- Takagi S, Utsunomiya K, Kuriyama S, et al. Effectiveness of an 'half elemental diet' as maintenance therapy for Crohn's disease: A randomized-controlled trial. Aliment Pharmacol Ther. 2006;24(9):1333-1340. doi:10.1111/j.1365-2036.2006.03120.x
- Wall CL, Gearry RB, Day AS. Treatment of Active Crohn's Disease with Exclusive and Partial Enteral Nutrition: A Pilot Study in Adults [published correction appears in Inflamm Intest Dis. 2018 Jul;2(4):236]. Inflamm Intest Dis. 2018;2(4):219-227. doi:10.1159/000489630
- Yang H, Feng R, Li T, et al. Systematic review with meta-analysis of partial enteral nutrition for the maintenance of remission in Crohn's disease. Nutr Res. 2020;81:7-18. doi:10.1016/j.nutres.2020.06.006
- Gkikas K, Gerasimidis K, Milling S, Ijaz UZ, Hansen R, Russell RK. Dietary Strategies for Maintenance of Clinical Remission in Inflammatory Bowel Diseases: Are We There Yet?. Nutrients. 2020;12(7):2018. Published 2020 Jul 7. doi:10.3390/nu12072018Critch J, Day AS, Otley A, et al. Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease [published correction appears in J Pediatr Gastroenterol Nutr. 2012 Apr;54(4):573]. J Pediatr Gastroenterol Nutr. 2012;54(2):298-305. doi:10.1097/MPG.0b013e318235b397
PEN and biologics
- Hisamatsu T, Kunisaki R, Nakamura S, et al. Effect of elemental diet combined with infliximab dose escalation in patients with Crohn's disease with loss of response to infliximab: CERISIER trial. Intest Res. 2018;16(3):494-498. doi:10.5217/ir.2018.16.3.494
PEN and surgery
- Adamina M, Gerasimidis K, Sigall-Boneh R, et al. Perioperative Dietary Therapy in Inflammatory Bowel Disease [published correction appears in J Crohns Colitis. 2022 Aug 16;:]. J Crohns Colitis. 2020;14(4):431-444. doi:10.1093/ecco-jcc/jjz160
- Chiu E, Oleynick C, Raman M, Bielawska B. Optimizing Inpatient Nutrition Care of Adult Patients with Inflammatory Bowel Disease in the 21st Century. Nutrients. 2021 May 9;13(5):1581. doi: 10.3390/nu13051581. PMID: 34065070; PMCID: PMC8151132.
- Shinozaki M, Yokoyama T, Saigusa N, et al. Elemental diet therapy plays a significant role in preventing surgical recurrence of Crohn's disease in the era of biologics. Surg Today. 2021;51(2):250-257. doi:10.1007/s00595-020-02112-5.
- Critch, Jeff*; Day, Andrew S.†; Otley, Anthony‡; King-Moore, Cynthia§; Teitelbaum, Jonathan E.||; Shashidhar, Harohalli# on Behalf of the NASPGHAN IBD Committee. Use of Enteral Nutrition for the Control of Intestinal Inflammation in Pediatric Crohn Disease. Journal of Pediatric Gastroenterology and Nutrition 54(2):p 298-305, February 2012. | DOI: 10.1097/MPG.0b013e318235b397
- Wilschanski M., Sherman P., Pencharz P., Davis L., Corey M., Griffiths A. Supplementary enteral nutrition maintains remission in paediatric Crohn’s disease. Gut. 1996;38:543–548. doi: 10.1136/gut.38.4.543
- Schulman J.M., Pritzker L., Shaoul R. Maintenance of Remission with Partial Enteral Nutrition Therapy in Pediatric Crohn’s Disease: A Retrospective Study. Can. J. Gastroenterol. Hepatol. 2017;2017:5873158. doi:10.1155/2017/5873158.
- Yamamoto T., Nakahigashi M., Saniabadi A.R., Iwata T., Maruyama Y., Umegae S., Matsumoto K. Impacts of long-term enteral nutrition on clinical and endoscopic disease activities and mucosal cytokines during remission in patients with Crohn’s disease: A prospective study. Inflamm. Bowel Dis. 2007;13:1493–1501. doi:10.1002/ibd.20238.
Role of adjuvant Crohn's disease exclusion diet plus enteral nutrition in asymptomatic pediatric Crohn's disease having biochemical activity: A randomized, pilot study
P589 Effectiveness of partial enteral nutrition to treat adults with Crohn's Disease who lost response to biological therapy.
Nutritional Therapy: Perioperative + Complicated Crohn's Disease
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