Multiple studies have suggested that IL-12/23 and IL-23 antagonists are potential therapeutic options for IBD treatment. Experts recommended IL-12/23 and IL-23 antagonists as a first- or second-line therapy because of their efficacy in biologic-naïve and experienced patients ( 90). Anti-integrin Therapy

The patient remained in remission for 27 months between April 2020 and July 2022. After a short period without Modulen and eating a free diet whilst overseas, the patient experienced a severe flare and obstruction in September 2022. The patient regained more control symptomatically by going on 6 weeks of EEN in addition to steroids and is now on phase 2 CDED+PEN (Modulen) again. CSs may be a kind of treatment selection for patients with UC who have not responded to mesalazine within 2–4 weeks, and those with mild-to-moderate CD, especially with extensive lesions ( 28). CSs have no proven efficacy in maintaining remission in IBD and should not be used for this purpose. Systemic oral CSs may result in numerous side effects, such as opportunistic infections, diabetes mellitus, hypertension, ocular effects, venous thromboembolism (VTE), osteoporosis, etc ( 29, 30). Steroid dependency or excess was found in ~15–40% of IBD patients ( 31, 32). Further investigation should define appropriate corticosteroid use and find measures for the improvement in CSs prescription management.Dugelay E, et al. Dietary zinc intake and inflammatory bowel disease in the French NutriNet-Santé cohort. Am J Gastroenterol. 2020 Aug;115(8):1293-1297. MRI showed 5–10 cm patchy ileocecal inflammation (ICV). Colonoscopy showed deep ulcers in ICV. The patient had previously demonstrated loss of response to infliximab, adalimumab and azathioprine, and was being treated with ustekinumab weekly. Chicco F, Magrì S, Cingolani A, et al. Multidimensional Impact of Mediterranean Diet on IBD Patients. Inflamm Bowel Dis 2020:27(1):1-9. Doi:10.1093/ibd/izaa097. Food diversity offered within CDED is particularly well appreciated by patients and provides motivation for complying with the treatment. Access to support material and multiple recipes through the Modulife App is an asset for patients, and the latter reduce monotony. New perspectives in dietary management of Ulcerative Colitis However, TPs have many adverse side effects, such as bone marrow suppression ( 50), liver injury ( 51), and gastrointestinal intolerance ( 44), etc. It has been reported that up to 39% of patients with IBD discontinue using TPs due to adverse reactions, most of which occur within 3 months of treatment ( 44). The use of TPs in IBD treatment has declined due to concerns about adverse drug reactions. MTX

In contrast with the well-established data on the potential of nutritional therapy to induce remission in active CD, limited data exist on the potential of dietary interventions to maintain remission. Cyclic administration of enteral nutrition tested in an open trial on eight children with CD markedly reduced the requirement of corticosteroids suggesting a role of dietary interventions as maintenance therapy. 39 Tagaki and colleagues 40 analysed the potential of daily partial enteral nutrition (50% of caloric support) in addition to a continued immunosuppressor (azathioprine) or anti-inflammatory therapy in adult patients with CD in remission. Supplementation with an elemental diet resulted in a reduced relapse rate from 64% to 34% in this trial. In the same line, the open pilot trial of Verma and colleagues 41 showed, in a heterogeneous cohort of adult patients with CD, that nutritional supplementation in addition to anti-inflammatory or immunosuppressive therapy had a beneficial effect allowing an increase in the rather low remission rate from 26% to 48%. Yamamoto and colleagues 42 prospectively compared 20 patients who received a continuous elemental diet infusion during the night time and a low-fat diet during the daytime with 20 patients who received neither nutritional therapy nor food restriction. On an intention-to-treat basis, 5 patients (25%) in the enteral nutrition group and 13 (65%) in the nonenteral nutrition group had a clinical relapse during the 1-year observation ( p=0.03). At 12months, endoscopic inflammatory scores were significantly higher in the nonenteral nutrition group than in the enteral nutrition group ( p=0.04).A short pilot study reported symptomatic improvement through excluding foods with high immunoglobulin (Ig)G4 levels (mostly eggs and beef). 64 Scarallo L et al., Crohn’s Disease Exclusion Diet in children with Crohn’s disease: a case series. CMRO. 2021, Volume 37, Issue 5. A somewhat different approach for inducing remission in patients with CD by the sole use of diet was recently reported by the Scottish group led by Professor Richard Russell with a diet called CD-TREAT. 47 This diet is based on an idea to mimic, with solid food, the composition and effects of enteral nutrition, particularly on the intestinal microbiota. In a first step, the authors compared the effect of CD-TREAT with EEN on the microbial composition and function (including short-chain acid and sulphite production) in healthy adult volunteers. A total of 25 healthy volunteers were randomized to receive EEN or CD-TREAT first and after a 2-week washout they were crossed over to the other treatment arm allowing individual comparison of changes in faecal microbiota and metabolome. As excepted, tolerance of CD-TREAT was superior to EEN, but the effects on gut microbiota composition and metabolic functions were comparable, encouraging the team after obtaining animal data confirming the anti-inflammatory potential of CD-TREAT to propose it to five children with active CD. After a course of 8weeks, four of five children responded to CD-TREAT, with three children achieving clinical remission. Only one patient normalized faecal calprotectin on CD-TREAT, the four other children showed a decrease from a mean 1960±1104mg/kg at baseline to a mean 1042±776mg/kg at 8weeks.

The rationale behind using UCED with PEN is: to support dietary intake with an oral liquid formula (pilot studies showed a decreased energy intake), to provide balance of micro- and macronutrients, to increase adherence and efficacy, to help deliver optimal fiber, and to help personalize recommendations. Sigall-boneh et al., Dietary therapies induce rapid response and remission in pediatric patients with active Crohn’s disease. Clin Gastroenterol Hepatol. 2021 Apr 1, Vol. 19, Issue 4, p.752-759. Another mechanism of dietary interaction with the host is via a direct effect on the immune system, where dietary antigens by themselves may trigger an immune response. The typical western-style diet, high in sugar and saturated fats and low in fibre, can lead to systemic low-grade inflammation, as described in obesity. 25 In animal models, the consumption of milk-derived saturated fats alters bile acid composition, allowing for a bloom of sulphate-reducing bacteria, which in turn can produce greater amounts of the potentially mucosal toxic hydrogen sulphide and production of helper T cell (Th1) proinflammatory cytokines. 26 Your diet can be helpful in managing your inflammatory bowel disease (IBD) during flares and periods of remission. Your healthcare team, including a registered dietitian specializing in IBD, may recommend a particular diet based on your symptoms.Racine A, et al. Dietary patterns and risk of inflammatory bowel disease in Europe: Results from the EPIC Study. Inflamm Bowel Dis. 2016 Feb;22(2):345-54.