Sheffield: Researchers from around the UK, led by a team at the University of
Sheffield’s Institute for Translational Neuroscience (SITraN), have
found new evidence to support early nutrition management in motor neuron
disease (MND). The first UK wide study into tube feeding in MND (ProGas) has found
that MND patients benefited most from enteral feeding when they had lost
less than 10 per cent of their body weight before the intervention.
In contrast, significant weight loss at the onset of enteral feeding was associated with shorter survival.
Based on the results of the study, published in the journal The Lancet
Neurology, the investigators recommend enteral feeding for MND patients
as early as possible at five per cent weight loss from MND diagnosis.
Chief
Investigator Dr Chris McDermott, Reader in Neurology at SITraN and
Consultant Neurologist at the MND Care and Research Centre at the
Sheffield Teaching Hospitals Foundation Trust, said: “These findings
will help health care professionals and patients to make informed
decisions about the choice of gastrostomy method and timing.”
The prospective multi-centre evaluation of gastrostomy in patients with MND (ProGas) included data from 24 centres in the UK.
A total of 330 patients in the study underwent gastrostomy which
entails the insertion of a tube in the stomach to facilitate enteral
feeding and were followed up for 12 months. The study aimed to provide
evidence on the benefits and timing of gastrostomy feeding, as well as
the optimum tube insertion method in terms of safety and clinical
outcome.
Study author Dr Theocharis Stavroulakis, Research Associate at
SITraN, who analysed the UK wide data said: “Although recommended by
both the American Academy of Neurologists and European Federation of
Neurological Societies, there was little evidence for the optimum method
and timing for gastrostomy.
"Decisions in clinical practice are currently largely based on
consensus and expert opinion. The aim of our study was to provide
evidence for the available treatment options and establish guidelines
for best clinical practice to improve care for MND patients.”
Enteral feeding is commonly used to support MND patients with severe
difficulties in swallowing (dysphagia). The three main methods of
gastrostomy currently used in MND patients are percutaneous endoscopic
gastrostomy (PEG), radiologically inserted gastrostomy (RIG), and
per-oral image-guided gastrostomy (PIG).
“The findings we present suggest that PEG might be the optimum method
of gastrostomy when respiratory function is largely unimpaired, and PIG
when respiratory function is significantly compromised,” said Dr
Stavroulakis.
“Both methods seemed to offer easier post-insertion tube management
than RIG. This is crucial in MND where loss of mobility and speech, as
well as breathing problems can increase the burden on both patient and
carer”.
The three gastrostomy methods were found to be as safe as each other
with respect to procedural risk, however RIG was found to be associated
with higher post-procedural complications associated with
balloon-retention gastrostomy tubes and more complex tube management.
PEG caused a higher rate of patient distress linked to procedure
tolerance.
There were no significant differences across the three methods in
terms of survival or weight change. The study showed that delay of
gastrostomy might lead to diminishing benefits, especially for patients
who at the time of gastrostomy have experienced excessive weight loss
from their diagnosis weight. The effect on the quality of life was
perceived neutral by the participants, however the burden for the carer
increased post-intervention.
The ProGas study was supported jointly by the Motor Neurone Disease
Association of England, Wales and Northern Ireland and the Sheffield
Institute for Translational Neuroscience at the University of Sheffield.
Director of Research at the UK MND Association Dr Brian Dickie said:
“The results of this research will underpin the development of clinical
guidelines to ensure greater consistency across MND clinics and improve
the outcomes of gastrostomy for those affected by this devastating
disease.
“Building on this evidence,” Dr McDermott said: “we now need to
better understand the specific nutritional requirements of MND patients,
particularly the quantity and quality of nutritional support that
patients receive after gastrostomy.”