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PubMed2001

Diagnostic value of anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease.

OBJECTIVES: Correct diagnosis of inflammatory bowel disease (IBD), especially the differentiation between Crohn's disease (CD) and ulcerative colitis (UC), is highly important toward treatment and prognosis. Serological markers are noninvasive diagnostic tools that could be of value in differentiating CD from UC, in cases of indeterminate colitis, and in the identification of subgroups in IBD. The aim of this study was to evaluate the diagnostic accuracy of perinuclear antineutrophil cytoplasmic (pANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA) for IBD. METHODS: ASCA and pANCA were studied in a large cohort of consecutive IBD patients (n = 582: 407 CD, 147 UC, and 28 indeterminate colitis), patients with non-IBD diarrheal illnesses (n = 74), and healthy controls (n = 157). An indirect immunofluorescence technique and a standardized ELISA were performed for detection of pANCA and ASCA, respectively. RESULTS: Prevalence of ASCA and pANCA was high in CD patients (59.7%) and UC (49.7%) patients, respectively. Positivity for both markers was significantly lower in healthy and non-IBD controls. Accuracy data (sensitivity, specificity, PPV, and NPV, respectively) for differentiating IBD from controls are as follows: ASCA+: 60% (243/407), 91% (345/378), 88% (243/276), and 68% (345/509); pANCA+: 50% (73/147), 95% (605/638), 69% (73/106), and 89% (605/679); ASCA+/pANCA-: 56% (229/407), 94% (355/378), 91% (229/252), and 67% (355/533); and pANCA+/ASCA-: 44% (65/147), 97% (620/638), 78% (65/83), and 88% (620/702). CONCLUSIONS: Specificity of serological markers for IBD is high, but low sensitivity makes them less useful as diagnostic tests. The combination of tests is probably more powerful, although, clinical subgroups still need to be defined. The usefulness of these markers in indeterminate colitis needs to be studied prospectively.

Adolescent↗
PubMed1999

Inflammatory bowel disease and pregnancy: a review.

Inflammatory bowel disease often occurs during peak reproductive years. Rates of conception, pregnancy outcome and disease course during pregnancy should be discussed prior to attempted conception. The majority of patients whose disease is well controlled prior to pregnancy should expect a fertility rate comparable to the general population, and an uncomplicated pregnancy with a favorable outcome. The disease should continue to be pharmacologically or surgically controlled as necesssary during pregnancy; the majority of drug options available to pregnant patients being without detriment to the fetus. No predictable inheritance pattern has been established and, at this time, there is no ability to screen prenatally.

Adult↗
PubMed1985

Inflammatory bowel disease.

The place of inflammatory bowel disorders in the spondarthritis matrix has been discussed and aetiopathological and clinicoradiological features of their individual arthropathies described. Particular emphasis has been placed on the arthropathies of ulcerative colitis and Crohn's disease, but a comment is also included on the much rarer condition, Whipple's disease. The position of reactive arthritis resulting from enteric infection in relation to the spondarthritis concept is examined in the light of Reiter's-like clinical features and the association with HLA-B27. More 'peripheral' ideas of possible relevance to the spondarthritis idea (drug-induced colitis, intestinal-bypass syndrome) are included, together with a final section on experimental models of inflammatory bowel disease and of their arthropathies. It is concluded that certain inflammatory bowel disorders deserve a continuing place within the spondarthritis complex. Although their aetiopathogenesis is still imperfectly understood, it is likely that a blend of genes of small effect (polygenic inheritance) and environmental factors (e.g. microorganisms and/or their products) trigger disease processes which are enabled to manifest themselves by intermediary immunological processes. The precise way in which this is achieved is not yet known, but there is evidence that microorganisms (presumably in the gut of individuals genetically predisposed and suitably exposed environmentally) generate the formation of immune complexes. It is likely that these not only damage or further damage the mucosal lining of the bowel but also result in arthropathy and features of the disease 'distant' from bowel and joint (e.g. ocular inflammation, oral ulceration and skin manifestations). This concept is summarized in Figure 5.

Adult↗
PubMed2005

[Treatment strategies for inflammatory bowel disease].

In patients with active inflammatory bowel disease (IBD), the objective is to achieve clinical remission. For ulcerative colitis (UC), oral or rectal aminosalycilates are widely used, and in more severe flares, corticoids and occasionally ciclosporine. In active Crohn's disease, corticosteroids represent the main treatment; budesonide must be preferred, as this steroid is better tolerated than prednisone. In patients refractory or intolerant to steroids, infliximab or artificial nutrition can be considered. Maintenance treatment is indicated in most of IBD patients. 5-ASA derivates are preferred in UC; in case of failure, azathioprine can be used. In Crohn's disease, azathioprine or methotrexate are more widely used; maintenance with infliximab is an option in case of failure. Surgery is mainly indicated for complications or in patients resistant to medical treatment.

Adrenal Cortex Hormones↗
PubMed2005

Effects of ferrous sulphate and non-ionic iron-polymaltose complex on markers of oxidative tissue damage in patients with inflammatory bowel disease.

BACKGROUND: Iron deficiency is a common complication of inflammatory bowel disease. Oral iron therapy may reinforce intestinal tissue injury by catalyzing production of reactive oxygen species. AIM: To compare the effects of ferrous sulphate and non-ionic iron-polymaltose complex on markers of oxidative tissue damage and clinical disease activity in patients with inflammatory bowel disease. METHODS: Forty-one patients with inflammatory bowel disease and iron deficiency were randomized to treatment with ferrous sulphate 100 mg twice a day or iron-polymaltose complex 200 mg once a day for 14 days. RESULTS: Following ferrous sulphate, plasma malondialdehyde increased (P = 0.02), while urine 8-isoprostaglandin F(2alpha) and plasma antioxidants did not change significantly. Iron-polymaltose complex did not change plasma malondialdehyde, urine 8-isoprostaglandin F(2alpha) or plasma antioxidants. Comparing the two treatments, changes in plasma malondialdehyde tended to differ (P = 0.08), while urine 8-isoprostaglandin F(2alpha) and plasma antioxidants did not differ. Neither ferrous sulphate nor iron-polymaltose complex altered clinical disease activity indices. CONCLUSIONS: Ferrous sulphate increased plasma malondialdehyde, a marker of lipid peroxidation. Comparing treatment with ferrous sulphate and iron-polymaltose complex, changes in plasma malondialdehyde tended to differ. Clinical disease activity was unchanged after both treatments.

Adolescent↗
PubMed2005

The emergence of inflammatory bowel disease in the Asian Pacific region.

PURPOSE OF REVIEW: Inflammatory bowel disease has been traditionally considered rare in the Asian Pacific region, but recent evidence indicates that both Crohn disease and ulcerative colitis are becoming increasingly common among local populations. This review will validate this significant epidemiological and clinical observation using data published in the current Asian literature and information presented at the 2004 Asian Pacific Digestive Week in Beijing, China. RECENT FINDINGS: A progressive rise in the incidence and prevalence of inflammatory bowel disease is discernible is most Asian Pacific countries, more so for ulcerative colitis than Crohn disease. Some ethnic differences are notably evident, as Indians suffer more inflammatory bowel disease than Chinese or Malays. Age of onset and gender are similar to those of Western patients, as are the distribution and extent of disease which, however, tends to be clinically less severe than in European and North American patients. A family history is occasionally elicited, whereas smoking and appendectomy appear to have the same impact on inflammatory bowel disease as seen in the West. A remarkable difference is the absence of any association of Asian Crohn disease with NOD2/CARD15 mutations, as repeatedly observed in white and Jewish populations. Intestinal tuberculosis is still common in the Asian Pacific region, and poses major diagnostic and therapeutic hurdles, often delaying the diagnosis of true Crohn disease. SUMMARY: Investigation of inflammatory bowel disease in the Asian Pacific region offers the unprecedented opportunity to study the 'early stages' of the disease, and may provide new clues to its pathophysiology by identifying key environmental factors and distinct genetic make-ups.

Asia↗
PubMed1992

Medical management of inflammatory bowel disease in a spider monkey.

Inflammatory bowel disease was diagnosed in a 3-year-old, captive-born, hand-raised, female spider monkey (Ateles geoffroyi). The diagnosis was based on clinical signs, positive-contrast radiographic series, endoscopy, histologic appearance of intestinal biopsy specimens, and the monkey's response to treatment. Treatment consisted of oral administration of prednisone, sulfasalazine, and trimethoprim-sulfamethoxazole. Supportive care included a bland diet and an electrolyte solution given free choice. Although several infective agents were considered, this case illustrates that recurrent enteritis in primates may be noninfectious and may respond to anti-inflammatory agents.

Animals↗
PubMed2004

Perinatal outcomes in inflammatory bowel disease.

OBJECTIVE: To determine whether inflammatory bowel disease (IBD) is associated with increased risk for adverse perinatal outcome. METHODS: A case-control study of 116 singleton pregnancies with IBD compared to 56,398 singleton controls delivered between 1986 and 2001. RESULTS: Patients with IBD were slightly older (32.8 vs. 30.6 years, p < 0.001), more likely to be Caucasian or Asian than Black or Latino (92% vs. 57%, p < 0.001) and have private health insurance (33% vs. 3%, p < 0.001). IBD was associated with an increased risk for labor induction (32% vs. 24%, p = 0.002), chorioamnionitis (7% vs. 3%, p = 0.04) and Cesarean section (32% vs. 22%, p = 0.007), but there were no differences in neonatal outcomes. Subgroup analysis demonstrated an increased risk for low birth weight (LBW) in the ulcerative colitis group vs. the Crohn's disease group (19% vs. 0%, p = 0.002). Patients with prior surgery for IBD had a lower incidence of LBW (0% vs. 12%, p = 0.03). Flares during pregnancy were associated with an increased risk for preterm delivery (27% vs. 8%, p = 0.02) and LBW (32% vs. 3%, p = 0.003). CONCLUSION: IBD was an independent risk factor for Cesarean section but there was no increase in adverse perinatal outcome. Crohn's disease, prior IBD surgery and quiescent disease were associated with a lower risk for LBW.

Adult↗
PubMed1998

Bone mineral density assessment in children with inflammatory bowel disease.

BACKGROUND & AIMS: Children with inflammatory bowel disease (IBD) are at risk for osteoporosis because of undernutrition, delayed puberty, and prolonged corticosteroid use. The aim of this study was to compare bone mineral density (BMD) in children with IBD with that in normal children and to assess the effects of nutritional and hormonal factors and corticosteroid dosages on BMD. METHODS: One hundred sixty-two subjects (99 with IBD and 63 healthy sibling controls) were enrolled. Patients underwent anthropometric assessment, pubertal staging, bone age radiography, and BMD assessment by dual energy x-ray absorptiometry of the lumbar spine, femoral neck, and radius. Laboratory evaluations included serum calcium, phosphate, alkaline phosphatase, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, parathyroid hormone, osteocalcin, urinary N-telopeptides, albumin, insulin-like growth factor I, and testosterone or estradiol. Cumulative corticosteroid doses were calculated. RESULTS: BMD Z scores at the lumbar spine and femoral neck were lower in patients with IBD, and lower in those with Crohn's disease compared with those with ulcerative colitis. Low BMD persisted after correction for bone age in girls with Crohn's disease (lumbar spine, P = 0.004; femoral neck, P = 0.002). Cumulative corticosteroid dose was a significant predictor of reduced BMD. BMD did not correlate with measures of calcium homeostasis, except elevated serum phosphate and urine calcium levels in girls. CONCLUSIONS: Low BMD occurs in children with IBD (more in Crohn's disease than in ulcerative colitis), especially pubertal and postpubertal girls. Cumulative corticosteroid dose is a predictor of low BMD, but other factors in Crohn's disease remain undetermined.

Adolescent↗
PubMed1984

Optic neuritis in inflammatory bowel disease.

It is not unusual for various ocular diseases to be associated with inflammatory bowel disease. Ocular involvement includes the inflammatory entities of keratitis, conjunctivitis, episcleritis, orbital pseudotumor, iritis and neuroretinitis , as well as those states in which the etiology remains undefined, i.e., scleromalacia perforans, peripheral corneal ulceration and furrow, retinal artery occlusion, and optic neuropathy. We report five cases of optic neuropathy associated with ulcerative colitis to emphasize that this may be the sole ocular manifestation of inflammatory bowel disease.

Adult↗
PubMedDate not supplied

Increased production of vascular endothelial growth factor by intestinal mucosa of patients with inflammatory bowel disease.

BACKGROUND/AIMS: Vascular endothelial growth factor (VEGF) is a heparin-binding glycoprotein with potent angiogenic, mitogenic and vascular permeability-enhancing activities specific for endothelial cells. Recent studies have shown significantly increased VEGF serum levels in patients with active Crohn's disease and ulcerative colitis. The origin of the circulating VEGF is not yet completely described. The present investigation examines the VEGF production of colonic mucosa in consideration of mucosal disease activity in patients with inflammatory bowel disease. METHODOLOGY: Fifteen patients with inflammatory bowel disease were studied, 9 patients with Crohn's disease and 6 patients with ulcerative colitis. Biopsies were taken from endoscopically inflamed and non-inflamed colonic mucosa. Therefore, an analysis of the spontaneous VEGF production of cultured biopsies without stimulus and of the histological grade of inflammation scored on a scale of 0-3 (normal mucosa--severe chronic colitis) were performed. Eight patients with irritable bowel syndrome served as controls. VEGF levels in the supernatant of cultured mucosal biopsies were measured using an enzyme linked immunosorbent assay. RESULTS: VEGF production is expressed as pg/mg wet weight of the biopsies. Inflamed mucosa of patients with active ulcerative colitis (16.27 +/- 10.39, p = 0.003, n = 6) and active Crohn's disease (9.88 +/- 5.98, p < 0.012, n = 9) showed a significantly higher spontaneous production of VEGF by colonic mucosa than normal mucosa of controls (3.16 +/- 1.63, n = 8). In addition, there was an increased unstimulated VEGF production by cultured inflamed mucosa of patients with Crohn's disease compared with non-inflamed mucosa (3.88 +/- 3.66, p < 0.015, n = 9). In both Crohn's disease and ulcerative colitis, there was no significant difference between VEGF production by non-inflamed mucosa and normal mucosa of controls. CONCLUSIONS: The present study identifies the intestinal mucosa as one of the origins of the elevated VEGF serum levels in patients with active inflammatory bowel disease and verifies the findings of recent studies about the importance of VEGF in Crohn's disease and ulcerative colitis.

Adult↗
PubMed1999

Fecal excretion of alpha 2-macroglobulin: a novel marker for disease activity in patients with inflammatory bowel disease.

BACKGROUND: Quantification of fecal alpha 1-antitrypsin (AAT) excretion is established for estimation of enteric protein loss and assessment of disease activity in inflammatory bowel disease (IBD). In contrast, little is known about prevalence, course, and clinical significance of intestinal leakage of larger-size serum antiproteinases in these disorders. SUBJECTS AND METHODS: Firstly, 23 IBD patients (Crohn's disease, CD, n = 17, and ulcerative colitis, UC, n = 6) were examined at 34 independent episodes (relapse, n = 16, remission, n = 18) for parallel serum and fecal alpha 2-macroglobulin (AMG) and AAT concentrations by standard immunonephelometry, and compared to 40 healthy controls. From these IBD patients, secondly, a random cohort of twelve individuals (9 CD, 3 UC) was prospectively followed for those parameters at about monthly intervals for 7-14 (median 10.5) months. RESULTS: The threshold of detection for fecal AMG concentration was about 0.06 mg per gram dry weight stool (mg/g dws) under the present analytical conditions. While in healthy subjects fecal AMG was demonstrated at very low levels only (< or = 0.07 mg/g dws), it was found in CD and UC patients at elevated concentrations of < 0.06-3.18 (median 0.17) and < 0.06-1.91 (median 0.40) mg/g dws, respectively. Fecal AMG contents were more increased in active IBD compared to quiescent disease (p = 0.03), and they correlated to Crohn's Disease Activity Index in CD patients (p = 0.05), while not to Clinical Activity Index in UC individuals (p = 0.46). Post hoc evaluation of follow-up data suggested two distinct groups of IBD patients either with or without consistently detectable fecal AMG excretion, with the first ones exhibiting a more active clinical course than the latter ones (p < or = 0.02). CONCLUSIONS: AMG is excreted in feces of healthy subjects in traces only, while its stool concentration is largely increased in IBD patients where it reflects clinical disease activity. This novel stool parameter may be of potential value in the diagnostic and prognostic management of these individuals.

Adolescent↗
PubMedDate not supplied

Polyunsaturated fatty acids (n-3 PUFAs) and inflammatory bowel disease (IBD): pathogenesis and treatment.

There is considerable evidence to suggest that polyunsaturated fatty acids (PUFAs) alleviate a number of inflammatory diseases, mainly the fish derivatives, n-3 PUFAs. My aim is to briefly review the literature involving clinical interventions with these lipid compounds in the treatment of Ulcerative Colitis (UC) and Crohn's Disease (CD), Inflammatory Bowel Disease (IBD). Data available are conflicting and the reason for the discrepancies in the findings could reside in the different study designs. Often studies are limited by the choice of placebo and insufficient washout period and direct comparison of trials is hampered by the use of various formulations and dosages of n-3 PUFAs. The importance of the n-3 PUFAs formulation in lowering the incidence of side effects along with careful selection of patients and experimental design seems to be associated with benefits. It is possible these fatty acids act by reducing low-grade active inflammation rather than by preventing reinitiation of the inflammatory process from a truly quiescent state. Whether this treatment is applicable to all patients with IBD has not been fully elucidated. Nevertheless, taken together, all these studies suggest the effectiveness of these new therapeutic approaches, not only when the conventional treatment fails or it is not possible to treat chronically, but also, in some instances as first choice.

Clinical Trials as Topic↗
PubMed2002

Potential viral pathogenic mechanism for new variant inflammatory bowel disease.

AIMS: A new form of inflammatory bowel disease (ileocolonic lymphonodular hyperplasia) has been described in a cohort of children with developmental disorder. This study investigates the presence of persistent measles virus in the intestinal tissue of these patients (new variant inflammatory bowel disease) and a series of controls by molecular analysis. METHODS: Formalin fixed, paraffin wax embedded and fresh frozen biopsies from the terminal ileum were examined from affected children and histological normal controls. The measles virus Fusion (F) and Haemagglutinin (H) genes were detected by TaqMan reverse transcription polymerase chain reaction (RT-PCR) and the Nucleocapsid (N) gene by RT in situ PCR. Localisation of the mRNA signal was performed using a specific follicular dendritic cell antibody. RESULTS: Seventy five of 91 patients with a histologically confirmed diagnosis of ileal lymphonodular hyperplasia and enterocolitis were positive for measles virus in their intestinal tissue compared with five of 70 control patients. Measles virus was identified within the follicular dendritic cells and some lymphocytes in foci of reactive follicular hyperplasia. The copy number of measles virus ranged from one to 300,00 copies/ng total RNA. CONCLUSIONS: The data confirm an association between the presence of measles virus and gut pathology in children with developmental disorder.

Adolescent↗
PubMed2004

[Association between the cytotoxic T lymphocyte antigen-4 gene microsatellite polymorphism and inflammatory bowel diseases in the Chinese].

OBJECTIVE: Inflammatory bowel disease (IBD) is characterized by chronic intestinal inflammation as a result of an exaggerated T-cell response. Cytotoxic T lymphocyte antigen-4 (CTLA-4) expressed mainly on activated T cells, inhibits T cell activation by combining B(7) through competing CD(28) and maintains immune system homeostasis. Polymorphisms in the CTLA-4 gene are known to be associated with several autoimmune diseases, but no studies related to IBD. The aim of the study is to investigate an association between CTLA-4 gene microsatellite polymorphisms and IBD. METHODS: Unrelated 68 Chinese Han patients with IBD (54 ulcerative colitis and 14 Crohn's disease) and 140 healthy controls were studied. The (AT)n repeat sequence in the 3' untranslated region of exon 4 were amplified by allele-specific PCR. The amplified products were electrophorosised by 12% polyacrylamid gel and followed by silver staining. RESULTS: Eighteen alleles of CTLA-4 microsatellite were found in Chinese patients and healthy individuals. Long allele, 122bp was apparently increased in patients with ulcerative colitis compared with healthy controls (7.4% vs 0.3%, P = 0.0002/Pc = Sig, OR = 22.32, 95% CI: 2.76 - 180.80). CONCLUSION: CTLA-4 gene microsatellite polymorphism was strongly associated with ulcerative colitis in Chinese Han patients in Hubei province.

Adult↗
PubMed1999

Diagnosis and management of inflammatory bowel disease.

The chronic, unpredictability of inflammatory bowel disease makes it difficult for patients to cope. In fact several studies quoted by Cox (1995) found that the Majority of IBD patients, even the one's who considered themselves "well," experienced some impairment in quality of life. Early detection of IBD is essential in developing patient confidence and providing motivation for cooperation in treatment. Irvine (1997) conducted a study dealing with the quality of life issues with IBD and concluded that despite impairments, most patients with IBD overcame the obstacles imposed by their illness and managed to remain productive members of society. Similar management (with anti-inflammatory drugs) makes differentiating between Crohn's disease and ulcerative colitis during the early stages of the disease, unnecessary. Situations that require differentiation include: right sided pain or tenderness, steatorrhea, nutritional deficiencies, or a palpable mass (Macrae & Bhathal, 1997). Although IBD continues to be of unknown etiology, recent advances and further study in the areas of the immune system, genetics and environmental influences may provide helpful treatment options in the future. For now, the clinician/patient goal must be to maintain adequate nutrition, promote healing, treat complications, and maintain an optimal lifestyle.

Adolescent↗
PubMed2003

Corticosteroids and immunomodulators: postoperative infectious complication risk in inflammatory bowel disease patients.

BACKGROUND & AIMS: Many patients with inflammatory bowel disease receive corticosteroids and 6-mercaptopurine/azathioprine during elective bowel surgery. We investigated the postoperative infection risk for patients undergoing elective bowel surgery who were receiving corticosteroids and/or 6-mercaptopurine/azathioprine before surgery compared with patients not receiving these medications. METHODS: A retrospective cohort study was conducted on 159 patients with inflammatory bowel disease who underwent elective bowel surgery. There were 56 patients receiving corticosteroids alone, 52 patients receiving 6-mercaptopurine/azathioprine alone or with corticosteroids, and 51 patients receiving neither corticosteroids nor 6-mercaptopurine/azathioprine. Postoperative infectious complications to time of discharge were categorized into major and minor complications. RESULTS: Patients receiving corticosteroids had an adjusted odds ratio for any and major infectious complications of 3.69 (95% confidence interval [CI], 1.24-10.97) and 5.54 (95% CI, 1.12-27.26), respectively. The adjusted odds ratio for patients receiving 6-mercaptopurine/azathioprine for any and major infectious complications was 1.68 (95% CI, 0.65-4.27) and 1.20 (95% CI, 0.37-3.94), respectively. CONCLUSIONS: Preoperative use of corticosteroids in patients with inflammatory bowel disease who are undergoing elective bowel surgery is associated with an increased risk of postoperative infectious complications. 6-Mercaptopurine/azathioprine alone and the addition of 6-mercaptopurine/azathioprine for patients receiving corticosteroids was not found to significantly increase the risk of postoperative infectious complications.

Adjuvants, Immunologic↗
PubMed2001

Intravenous cyclosporine in refractory pyoderma gangrenosum complicating inflammatory bowel disease.

BACKGROUND: Pyoderma gangrenosum complicates inflammatory bowel disease in 2-3% of patients and often fails to respond to antibiotics, steroids, surgical debridement or even colectomy. METHODS: We performed a retrospective chart analysis of 11 consecutive steroid-refractory pyoderma patients (5 ulcerative colitis, 6 Crohn's disease) referred to our practice and then treated with intravenous cyclosporine. Pyoderma gangrenosum was present on the extremities in 10 patients, the face in 2, and stomas in 21. At initiation of intravenous cyclosporine, bowel activity was moderate in 3 patients, mild in 4, and inactive in 4. All patients received intravenous cyclosporine at a dose of 4 mg/kg/d for 7-22 days. They were discharged on oral cyclosporine at a dose of 4-7 mg/kg/d. RESULTS: All 11 patients had closure of their pyoderma with a mean time to response of 4.5 days and a mean time to closure of 1.4 months. All seven patients with bowel activity went into remission. Nine patients were able to discontinue steroids, and nine were maintained on 6-mercaptopurine or azathioprine. One patient who could not tolerate 6-mercaptopurine had a recurrence of pyoderma. No patient experienced significant toxicity. CONCLUSION: Intravenous cyclosporine is the treatment of choice for pyoderma gangrenosum refractory to steroids and 6-mercaptopurine should be used as maintenance therapy.

Adrenal Cortex Hormones↗