Prevention of Acute Diverticulitis and DICA Score -Eur.J.Gastroenterol.Hepatol Jan 26

The prevention of acute diverticulitis (AD) based on the DICA (Diverticular Inflammation and Complication Assessment) score offers several key insights and takeaways for individualized management strategies. Below is a detailed summary:

### 1. **Introduction to the Problem**

Acute diverticulitis (AD) is a common complication in patients with colonic diverticulosis, and its prevention remains a significant unmet clinical need. The DICA score provides an endoscopic stratification system to assess the risk of developing AD, enabling tailored interventions for patients based on their individual risk profiles. This study investigated the effectiveness of various preventive strategies, including no treatment, high-fibre diet, mesalamine, rifaximin, and a combination of mesalamine and rifaximin, in reducing the risk of AD over a 3-year period.

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### 2. **Key Findings from the Study**

#### **Overall Risk of Acute Diverticulitis**

• During the 3-year follow-up, 140 cases of acute diverticulitis were documented.
• The **lowest crude 3-year AD risk** was observed in the **no-treatment group (3.3%)**, followed by:
• **High-fibre diet (5.9%)**
• **Mesalamine alone (9.5%)**
• **Rifaximin alone (11.8%)**
• **Combination therapy (mesalamine + rifaximin) (17.1%)**

#### **Effectiveness of Preventive Strategies**

• **Mesalamine** showed a significant benefit in reducing the risk of AD compared to rifaximin and combination therapy:
• Mesalamine reduced the hazard of AD by **58%** compared to rifaximin (HR 0.42; 95% CI 0.19–0.94).
• Mesalamine reduced the hazard of AD by **63%** compared to combination therapy (HR 0.37; 95% CI 0.15–0.88).
• **Rifaximin** was associated with a **higher hazard of AD** compared to no treatment, suggesting it lacks preventive benefits.
• **Combination therapy** (mesalamine + rifaximin) showed the **highest crude incidence** of AD, indicating no synergistic benefit.

#### **DICA Score-Based Stratification**

• Treatment effects varied according to the DICA classification, emphasizing the importance of endoscopic risk stratification:
• **DICA 2 Patients** derived the greatest benefit from mesalamine therapy.
• Mesalamine reduced AD risk by **77%** compared with rifaximin (HR 0.23; 95% CI 0.08–0.62).
• Mesalamine reduced AD risk by **84%** compared with combination therapy (HR 0.16; 95% CI 0.05–0.53).
• In DICA 2 patients, mesalamine emerged as the most effective preventive strategy.
• The benefit of mesalamine over no treatment was not clearly established across all DICA scores.

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### 3. **Conclusion: DICA-Guided Individualized Approach**

The findings support the use of a **DICA-guided individualized approach** to AD prevention rather than a uniform pharmacologic prophylaxis strategy. Key conclusions include:

• Mesalamine demonstrates significant preventive benefits, particularly for patients with intermediate-risk disease (DICA 2 classification).
• Rifaximin and combination therapy (mesalamine + rifaximin) are not effective and may even increase the risk of AD.
• The no-treatment strategy showed the lowest crude risk of AD, raising questions about the necessity of pharmacologic interventions in certain patient groups.
• Endoscopic risk stratification using the DICA score is essential for identifying patients who may benefit from targeted preventive measures, optimizing outcomes, and avoiding unnecessary treatments.

In summary, **mesalamine therapy tailored to DICA 2 patients** is the most effective strategy for reducing AD risk, highlighting the importance of individualized, risk-based management approaches in clinical practice.