A Cochrane review included 11 studies with a total of 467 subjects, examining treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. The efficacy of 10 different pharmacologic agents was assessed. For the treatment of acute pouchitis (4 studies, 5 agents), ciprofloxacin was more effective at inducing remission than metronidazole (Peto OR 14.39, 95% CI 2.00 to 103.76; 1 study, n=16). Neither rifaximin (Peto OR 10.92, 95% CI 0.62 to 193.55; 1 study, n=18) nor lactobacillus GG (Peto OR 7.39, 95% CI 0.15 to 372.38; 1 study, n=20) were more effective than placebo, while budesonide enemas and metronidazole were similarly effective for inducing remission of acute pouchitis (budesonide compared to metronidazole, Peto OR 1.32, 95% CI 0.29 to 6.01; 1 study, n=26). For the treatment and maintenance of remission of chronic pouchitis (4 studies, 4 agents), glutamine suppositories were not more effective than butyrate suppositories (The Peto odds ratio for maintenance of remission with glutamine compared to butyrate was 2.75, 95% CI 0.48 to 15.94; 1 study, n=19), and bismuth carbomer foam enemas were not more effective than placebo (Peto OR 1.00, 95% CI 0.29 to 3.42; 1 study, n=40), while VSL#3 (Oral VSL-3 probiotic bacterial formulation) was more effective than placebo in maintaining remission of chronic pouchitis (Peto OR 25.39, 95% CI 10.37 to 62.17; 2 studies, n=76) in patients with chronic pouchitis who achieved remission with antibiotics. For the prevention of pouchitis (3 studies, 2 agents), in one study VSL#3 was more effective than placebo (Peto OR 4.76, 95% CI 1.16 to 19.56; n=40) while in another study VSL#3 was not more effective than no treatment (Peto OR 10.31, 95% CI 0.20 to 541.25; n=28). Allopurinol was not more effective than placebo (Peto OR 1.10, 95% CI 0.62 to 1.97; 1 study, n=184), while inulin was more effective than placebo but the results were not clinically significant.
A systematic review including 4 studies with a total of 112 subjects was abstracted in DARE. Oral metronidazole for 7 days (n = 13) significantly decreased stool frequency (at least by 3 stool/24h), OR 12.34, 95% CI 2.23 to 64.95), absolute risk reduction 0.64, NNT = 1.56. Oral probiotic therapy for 9 months (n = 40) reduced relapse rate, OR 15.33, 95% CI 4.51 to 52.14), absolute risk reduction 0.85, NNT = 1.18. Bismuth carbomer was not effective.
Comment:The quality of evidence is downgraded by study quality (unclear allocation concealment) and by imprecise results (few patients and wide confidence intervals).