There is a strong link between tnf alpha and mitochondrial dysfunction. But to what extent would anti tnf therapy be useful in nsaid enteropathy as tnf levels are also required for knowing the state of the disease condition?
I am a bit confused about this question. NSAID-induced enteropathy is an iatrogenic condition, taking a number of different clinical forms including GI ulceration and bleeding in the upper and lower GI tract, pseudomembrane formation in the lower intestines, etc. At least one of the mechanisms is COX-1 inhibition, the reason selective COX-2 inhibitors, e.g., celecoxib were developed. The treatment of NSAID-induced enteropathy is to discontinue the NSAID. It can be prevented to some extent by the concomitant use of PPIs, e.g., Nexium, Protonix, etc. Contributing factors to the development of NSAID-induced enteropathy include smoking, the use of steroids, previous history of GI bleed, alcohol ingestion, infection with H. pylori, multiple medical problems, advanced age, etc, working alone or in combination. I am not sure how anti-TNF intervention would fit here,
Dear Sir
By NSAID enteropathy i maean damage to small intestine only. NSAIDs are prescribed for symptomatic relief in RA patients and it has been reported that NSAID alone or in combination with PPIs damage intestine.
Anti TNF agents are highly effective against NSAID enteropathic damage in clinical studies so there has to be some relationship (Pls see attachment) . Please throw some light in this regard.
Thank you for bringing this up to my attention. However, this article presents more questions than it provides answers. I don't think we have any convincing data to say that anti-TNF agents are highly effective against NSAID enteropathy. Also, the concomintant use of NSAID with a PPI has been shown several times to be protective of NSAID gastro-enteropathy. It is common knowledge by now. This is why we recommend the combination clinically. All we can say at this point is that in this study, the incidence of NSAID enteropathy was lower in the anti-TNF-treated group of RA patients. That's it. Is there a cause and effect for the role of TNF here or is this just an epiphenomenon? Does the finding of less severe damage by capsule endoscopy correletae with less frequent clinical bleeding? A lot of endoscopically-documented superficial erosions never become ulcers, and they tend to heal on their own. NSAID enteropathy is uncommon to rare to beging with. Gastric ulcer bleed is more common. And different NSAIDS carry different degrees of ulcerogenicity, with indomethacin and ibuprofen being the worst offenders, along with diclofenac. The authors suggest that perhaps anti-TNF intervention may be of help for patients who continue to take aspirin and develop aspirin enteropathy. I think this is really pushing the concept a bit far, in my opinion. Let me end by paraphrasing what the authors themselves said: "However, further studies are required to determine whether the anti-TNF biological agents exert these two effects (a protective effect and a wound-healing effect) in NSAID-induced enteropathy". In other words, more data is needed.
Dear Sir, Thank you for answering my queries and whatever you have told is absolutely fine. As far as the occurrence of NSAID enteropathy is concerned Dr John L wallace along with others have worked on this disorder from last 20 years if not more. Recently published article throws more light in that regard (Pls see attachment 1). I agree that there is no substantial data till date to establish a relationship between NSAID enteropathy and TNF but it is also true that there are no therapies for NSAID enteropathy.
My question is if a patient who is on NSAID complains of lower abdominal pain then what treatment is given? why Probiotics are useful in NSAID enteropathy? Now there is established relationship between LPS-TLR4-MyD88 pathway-COX2-PGs-and their effects. TNF being the primary cytokine released from TLR4-MyD88-NF-kappa B pathway from macrophages and COX2 being induced at the same site (Pls see attachment 2), and the involvement of TNF in mitochondrial dysfunction, alteration of intestinal permeability makes it very interesting.
I know i may be stretching it too far, But i am just trying to answer myself.
Regards
Thank you. I agree this is a fascinating area of research. I don't dispute any of the basic science data you present. Who knows? It may well be that blocking the involved pro-inflammatory cytokines in this condition, e.g., TNF alpha may offer some clinical benefit to these patients with NSAID-induced enteropathy. My best wishes in your research work,
Dear Sir
Thank you for patiently answering my queries and kind words of yours. I believe you will help me in this area of research.
Regards
Hi everyone, after considering all the possible aspects we have written this paper. Your views and comments are invited
Article Clinical importance of NSAID enteropathy: The relevance of T...
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