Immunomodulators are important for patients with IBD and mainly include thiopurines (TPs), methotrexate (MTX), calcineurin inhibitors, and Janus Kinase (JAK) inhibitors. The studies on the efficacy and safety of immunomodulators in IBD are summarized in Supplementary Table 1. TPs Khalili H, et al. Adherence to a Mediterranean diet is associated with a lower risk of later-onset Crohn's disease: results from two large prospective cohort studies. Gut. 2020 Sep;69(9):1637-1644. From the database's inception until October 2021, we conducted a comprehensive search in PubMed and Web of Science. The retrieval strategy is based on Medical Subject Headings (MeSH) and corresponding free words. The major search terms are as follows: “Inflammatory Bowel Disease,”“Bowel Diseases, Inflammatory,”“IBD,”“Crohn's Disease,”“Crohn's Enteritis,”“Ulcerative Colitis,”“Colitis Gravis,”“Aminosalicylates,”“Mesalazine,”“5-Aminosalicylic Acid,”“Corticosteroids,”“Thiopurines,”“Methotrexate,”“Calcineurin Inhibitors,”“Biologics,”“Janus Kinase inhibitors,”“Ozanimod,”“Etrasimod,”“Surgical Procedure,”“Apheresis,”“Blood Component Removals,”“Antibiotics,”“Antibacterial Agents,”“Probiotics,”“Prebiotics,”“Synbiotics,”“Postbiotics,”“Fecal Microbiota Transplantation,”“Stem Cell Transplantations,”“Exosomes,”“Diet.” The above search terms were connected by the logical operators “OR” or “And.” The research focused on the treatment of IBD. A total of 9,885 references were retrieved. Studies, which are old, repetitive and non-English and those without clear information were excluded. We selected some representative scientific papers and 257 references were finally quoted. Pharmacological Intervention Side effects associated with 5-ASA, including flatulence, nausea, abdominal pain, diarrhea, and headache, are generally mild. In contrast, the side effects of SASP, such as infertility, hemolytic anemia, photosensitization, and granulocytosis, are much more than those of 5-ASA ( 12). However, a few patients may develop nephrotoxicity within 1 year of 5-ASA administration ( 23). CSs

Compared to other available therapies, these results were very encouraging. As a result, guidelines set by the European Society for Clinical Nutrition and Metabolism (ESPEN) 26 recommend that: “CD exclusion diet (plus partial EN) should be considered as an alternative to exclusive EN in pediatric patients with mild to moderate CD to achieve remission.” For adults, a lower grade recommendation suggests that: “A CD exclusion diet can be considered with or without EN in mild to moderate active CD.” The expert panel commented that this should be further demonstrated with additional studies. The effects of nutrition and diet on the host are multiple: food ingredients can directly interact with epithelial cells or under certain conditions with the immune system, as well as indirectly via gut microbiota. Gut microbiota form a complex and dynamic system with a steady state, which can be perturbed by many environmental factors, including diet. A homeostatic balance of the host–bacteria relationship is important and vital for a normal health process. An imbalanced intestinal microbiota termed ‘dysbiosis’ has been repeatedly seen in IBD and is now recognized as a key factor in gut inflammation. 12 Sokol and colleagues 13 showed a significant decrease in the proportion of the Clostridium leptum phylogenetic group in patients with colonic CD. These results were confirmed by a metagenomic approach, revealing a restriction in biodiversity depending on bacteria belonging to the Firmicutes phylum ( C. leptum and Clostridium coccoides) with a decrease in the proportion of bacteria belonging to the C. leptum phylogenetic group. 14, 15 This dysbiosis is characterized by a high instability of the microbiota over time, the presence of approximately 30% of unusual bacteria, a marked increase in mucosal bacterial concentration, and a restriction in biodiversity regarding the Firmicutes phylum. Within this group, a decrease in C. leptum has been shown and particularly its major representative, Faecalibacterium prausnitzii. 12 There is also emerging evidence of the effectiveness of CDED in adults. 21,22 To further consolidate these findings a new multicentric RCT, the PARADISE study, has been initiated to explore CDED+PEN vs prednisone for induction of remission in adult CD patients. Diets for the management of IBD: Where we stand and future perspectives Clinical outcomes were consistent in adults and children. 60% of adults achieved clinical response vs 71% of children. 40% of adults and 38% of children achieved clinical remission.Dupa preparare consumați soluția în termen de 6 ore dacă a fost păstrată la temperatura camerei sau în 24 ore dacă a fost păstrată la frigider; D Chan, et al. Inflammatory bowel disease and exercise: results of a Crohn's and Colitis UK survey. Frontline Gastroenterol. 2014 Jan;5(1):44-48. A randomized controlled trial demonstrated that more than 80% of patients with severe acute refractory UC responded to CsA ( 58). It has been reported that the 8-day clinical remission rate (84.2 vs. 85.7%) of patients with severe UC treated with intravenous 4 mg/kg CsA is similar to that of patients treated with intravenous 2 mg/kg CsA ( 59). Stange et al. performed a randomized controlled trial to delineate the long-term effect of CsA on chronic active CD and found that CsA combined with low-dose steroids had no advantage over the sole use of low-dose steroids ( 60). 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. The patient was reloaded with ustekinumab and reduced from 8 to 6 weekly; however, fecal calprotectin (FC) continued to rise (2094 μg/g). She was then referred for EEN.

Fibre may play a more complex role in IBD than previously recognised. Current data suggest that the response to fibre is influenced by diet, microbes, the gut barrier, immune cells and active inflammation.Following this study, a number of reports confirmed the effectiveness of CDED+PEN in practice, making CDED a well-recognized and important alternative to EEN. Median Pediatric Ulcerative Colitis Activity Index (PUCAI) decreased from a baseline of 35 (30–40) to 12.5 (5–30) at week 6 (p=0.001).