Escherichia coli for ulcerative colitis (1999)

Authors' reply Sir—M J S Langman and R N Allan underscore the high relapse rates in our study, which is an important point that we discussed at length. A systematic review from the Cochrane database found that 5-aminosalicylic acid was significantly more effective than placebo, but that there was no difference in efficacy between different formulations or doses.1Sutherland L Roth D Beck P May G Makiyama K The use of oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis. In: Cochrane Library [CDROM and online]. Cochrane Collaboration; issue 3. Update Software, Oxford1997Google Scholar Despite this finding, studies have reported a wide range of relapse rates, with different aminosalicylates, which may differ by a factor of five between different studies.2Rijk MC van Lier HJ van Tongeren JH Relapse-preventing effect and safety of sulfasalazine and olsalazine in patients with ulcerative colitis in remission: a prospective, double-blind, randomised multicenter study..Am J Gastroenterol. 1992; 87: 438-442PubMed Google Scholar, 3Kiilerich S Ladefoged K Rannem T Ranlov PJ Prophylactic effects of olsalazine vs sulphasalazine during 12 months maintenance treatment of ulcerative colitis..Gut. 1992; 33: 252-255Crossref PubMed Scopus (56) Google Scholar, 4Riley SA What dose of 5-aminosalicylic acid (mesalazine) in ulcerative colitis?.Gut. 1998; 42: 761-763Crossref PubMed Scopus (53) Google Scholar, 5Riley SA Mani V Goodman MJ Herd ME Dutt S Turnberg LA Comparison of delayed-release 5-aminosalicylic acid (Mesalazine) and sulfasalazine as maintenance treatment for patients with ulcerative colitis..Gastroenterology. 1988; 94: 1383-1389PubMed Google Scholar Because there is no evidence that the use of different formulations or doses is responsible for the wide variation in relapse rates, there must be alternative explanations. When we reviewed published studies, we found that previous studies had recruited patients at variable durations of remission and then reviewed them at a few fixed timepoints during the year, commonly in different hospitals and by different physicians. The risk of relapse may be lowest when patients are recruited into trials during a long period of remission and highest when they are recruited soon after an exacerbation. To reduce bias we chose to recruit patients at the same timepoint (ie, during the active stage of disease), and then followed them prospectively into remission and relapse. Furthermore, patients were given the contact number of a single physician who reviewed them in our open-access clinic. Our approach reduces bias by standardising the population, and encourages patients to report changes in symptoms at an early stage. We believe that our results accurately reflect the high risk of relapse in these patients. Langman and Allan question the wording of our summary. Even “the unwary reader” should have noted that it was clearly stated (on two occasions) and discussed that all patients with active disease received standard medical therapy, and that our suggestion of an equivalent effect of non-pathogenic E coli referred only to the maintenance of remission. Escherichia coli for ulcerative colitisB J Rembacken and colleagues (Aug 21, p 635)1 report the use of non-pathogenic Escherichia coli to treat ulcerative colitis. They suggest that the equivalence of duration of remission in mesalazine-treated patients to that in E coli-treated patients implies an equivalent treatment effect. We think that this may be optimistic. Relapse within 1 year was frequent in individuals treated with mesalazine and E coli (73% and 67%, respectively). These relapse rates are very similar to those seen in studies of relapse frequency in placebo recipients in trials of sulphasalazine. Full-Text PDF