Preventing Recurrent Acute Diverticulitis With Pharmacological Therapies

Ther Adv Chronic Dis. 2013;4(6):277-286.

Conclusion

After this literature review, an empirical therapeutic approach can be suggested in preventing diverticulitis relapses (Figure 1). However, some questions remain unanswered

Proposed treatment algorithm after acute diverticulitis. CT, computed tomography.

Why have the studies assessing medical treatment in preventing diverticulitis recurrence given divergent results? And what research questions remain unanswered? One of the possible explanations for the disappointing results is that most of the trials assessing prevention of diverticulitis recurrence fail to enroll an adequate sampling size. The DIVA trial [Stollman et al. 2013], the DIV/09 trial [Parente et al. 2011] and the Lanas trial [Lanas et al. 2013] failed to enroll the planned number of patients. This led to disappointing results that affected the importance of the study and increased the number of unanswered questions. What factors affect the inadequate sampling size in that disease? Underevaluation of the complication of the disease? Underevaluation of the burden of the disease to patients and the particular health system? Or, more simply, an overall underevaluation of diverticulitis that is still considered a little bit more than a ‘complex irritable bowel syndrome’ by several physicians?

Other important points to investigate in the future is whether a different mesalazine formulation may influence the response to treatment, as well as whether probiotics may be advised in treatment because of their ‘bacterial control’ and immune stimulation.Can these somewhat conflicting data currently be used to guide a patient? Despite the fact that most currently available data are inconclusive for many reasons (lack of controlled studies, preliminary data published as abstract but not as full paper, different primary and secondary endpoints, etc.), the following points have clearly been shown:

A high-fiber diet, as well as cyclic non-absorbable antibiotics, is ineffective in preventing diverticulitis recurrence, even in the absence of any controlled study.Data from double-blind, placebo-controlled studies are inconclusive about the effectiveness of mesalazine in preventing diverticulitis recurrence; however, it seems to be effective in controlling symptoms after an acute episode.
The use of probiotics cannot be advised due to a lack of controlled trials.

In conclusion, current studies about conservative prevention of diverticulitis relapses lead to more questions than answers. Much more investigation is required before answers to these questions are found.