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IBD Treatment - Quiet the Inflammation

April 27th, 2011

Inflammatory bowel disease (IBD) is an umbrella term used to describe a group of inflammatory disorders of the gastrointestinal tract. Each of these disorders involves some degree of inflammation (redness, swelling, erosion and sometimes bleeding) of the gastrointestinal mucosa or lining that commonly leads to ulceration of the mucosa to varying degrees. The inflammation is usually a result of an immune reaction of the body against its own intestinal tissue. Therefore, the diseases included in IBD are considered to be autoimmune disorders.

IBD Treatment - Quiet the Inflammation (reduce production of inflammatory mediators)

This is Part 4 of a 5-part article including:

1. An Integrated Approach to Managing Inflammatory Bowel Disease

2. Diagnostic Evaluation of IBD

3. IBD Treatment: Remove the Obstacles to Cure

4. IBD Treatment: Quiet the Inflammation

5. IBD Treatment: Repair the Gut

(or, download the PDF of the entire article)

The following nutritional and botanical products have been demonstrated to be safe, effective anti-inflammatory compounds beneficial in the treatment and management of IBD (according to the existing peer-reviewed scientific literature). Their use can help to limit reliance on heavier doses of medications known to have more side effects.

That said, each case of IBD is different in its presentation and degree of severity. I am in no way suggesting the following nutritional and botanical therapies can successfully treat and manage IBD by themselves. I commonly use them in combination with conventional medications and conservative medical management. However, a number of my patients have successfully weaned off the more potent medications such as Azathioprine, 6-mercaptopurine, prednisone and others after being symptom-free for 6-12 months or longer on the integrated treatment regime described below.

Please remember, any use of additional medications or changes in treatment should only be made with your physician’s guidance and knowledge.

Curcuma longa (Curcumin)

Curcumin is a flavonoid extract from the spice turmeric (Curcuma longa). It is one of the most studied natural compounds in the world due to its marked anti-inflammatory and anticancer activity. It safely and actively inhibits production and release of numerous pro-inflammatory chemicals that are involved in the inflammatory process of IBD.

Curcumin causes:

  • Inhibition of cyclooxygenases/COX-2 (This is how sulfasalazine and mesalamine work.)

  • Inhibition of lipoxygenase (LOX)

  • Inhibition of TNF-alpha (This is how Remicade works.)

  • Inhibition of IFN-Gamma

  • Inhibition of the transcriptional nuclear factor kappa B (NF-kappa B) - a key factor in the upregulation of inflammatory cytokines

Clinical research demonstrates Curcumin can significantly reduce clinical relapse in patients with quiescent IBD. Quoting researchers from the Center for Gastroenterology and Inflammatory Bowel Disease Research at Hamamatsu South Hospital, Hamamatsu, Japan, “The inhibitory effects of curcumin on major inflammatory mechanisms like COX-2, LOX, TNF-alpha, IFN-gamma, NF-kappaB and its unrivalled safety profile suggest that it has bright prospects in the treatment of IBD.” (9)  

Gum Resin Extract from Boswellia serrata

The gum resin extract from Boswellia serrataa (Frankincense) has also been shown to be of value in the treatment of IBD and chronic inflammation overall. According to researchers, “Oral therapy with the Boswellia extract or AKBA significantly reduces macroscopic and microcirculatory inflammatory features of inflammation in IBD.”10 The anti-inflammatory actions of Boswellia extract appear to be primarily due to its ability to inhibit 5-lipoxygenase, a potent activator of inflammation. This is the same anti-inflammatory activity that makes the aminosalicylate (aspirin-related) drugs such as sulfasalazine, olsalazine, mesalamine and azulfidine commonly used to treat IBD so beneficial. Boswellia has been further shown to inhibit other activators of inflammation such as NF-kappa B. (11, 12)

In clinical studies, medicinally effective oral doses of Boswellia reduced mucosal injury by inhibiting activity and adherence of activated leukocytes to intestinal mucosal cells in patients with IBD. (13) In one clinical study of Boswellia and IBD, Boswellia serrata gum resin preparation (350 mg TID for 6 weeks) was given to ulcerative colitis patients. Stool properties, biopsies, and various blood parameters were studied. Patients receiving sulfasalazine (1 g thrice daily) served as controls. “All parameters tested improved after treatment with Boswellia serrata gum resin, the results being similar compared to controls: 82% out of treated patients went into remission; in case of sulfasalazine remission rate was 75%.” (14)

Fish Oils (EPA/DHA)

Fish oils have been studied for nearly 30 years for their health giving benefits, their anti-inflammatory capability in particular. They have been shown to effect the production of the chemical mediators of inflammation called prostaglandins by reducing those that promote inflammation while increasing those that reduce inflammation. Quoting researchers from the scientific journal, Nutrition,

“Fish oils have been used successfully in the management of several inflammatory and autoimmune diseases. The potential for the use of fish oils in the management of these diseases is tremendous…" (15)

Experimental/epidemiological studies show fish/n-3 polyunsaturated fatty acids have anti-carcinogenic effects in the colon as well. (16) This is particularly important for people with IBD as they are at much higher risk than the normal population for developing colon cancer.

In studies with IBD, fish oils have been found to be safe and effective nutritional therapies for maintaining remission. After reviewing the published medical studies using fish oils in the treatment of IBD, the researchers concluded, “Omega 3 fatty acids are safe and may be effective for maintenance of remission in Crohn’s disease when used in enteric coated capsules." (17)

Deglycyrrhizinated licorice (DGL)

Licorice root has had a long history of medicinal use. In clinical studies, it has been shown to reduce inflammation in gastric mucosa and promote healing of ulcers while reducing recurrence. Human studies have found it to be as effective as leading anti-ulcer medications in relieving pain associated with stomach ulcers and preventing the ulcers from recurring. It also promotes the healing of canker sores commonly associated with Crohn’s disease while reducing the associated pain.

Specific Carbohydrate Diet (SCD)

The Specific Carbohydrate diet is my first choice in the treatment of IBD and should include organic, whole foods and free-range, grass-fed animal protein. It reduces exposure to high dietary intakes of sucrose, refined carbohydrates, and microparticles (anti-caking agents, food additives) which may combine with various gut bacteria such as Klebsiellala thereby enhancing their ability to cause cross-reactive immune responses leading to inflammation locally in the gut and systemically.

People with Crohn’s disease and reactive arthritis such as ankylosing spondylitis, have been found to have elevated levels of antibody against the whole bacteria or preparations from Klebsiella along with antibodies to the connective tissues of their joints and cartilage (collagen) due to molecular similarities between their genetic markers for certain proteins and Klebsiella. (18) Therefore, reducing the immune reactivity and cross-reactivity to these bacteria may reduce the body-wide inflammation IBD can cause.

A “low starch diet” like the Specific Carbohydrate Diet has been shown to reduce the levels of specific bacterial cross-reactive antibodies in both healthy controls and patients with IBD and reactive arthritis. Further, it has also been shown to decrease the inflammation and symptoms in those patients.19 Researchers suggest, “Early treatment of Crohn’s disease patients with anti-Klebsiella measures is proposed, which may involve the use of antibiotics and low starch diet together with other traditionally used immunomodulatory, immuno-suppressive, or biologic agents.” (20)

Corticosteroids (Prednisone or Budesonide)

Corticosteroids, such as prednisone, are prescriptive, suppressive, anti-inflammatory medications used to treat acute exacerbations of IBD. Every clinician I know prefers not to use these drugs for long-term management of IBD if at all possible, due to their eventual side effects such as diabetes, osteoporosis, stomach ulcers and others when used over prolonged periods. However, with that said, prednisone can save lives when given at the right time, with the right patient, in the right tapering doses. Prednisone tapers for acute exacerbation of IBD commonly begin with doses in the range of 40 to 60 mg daily, slowly tapering down over 6 to 12 weeks. Budesonide is an intra-luminal (stays within the intestine) steroid that is commonly effective in treating IBD, particularly microscopic colitis. Its benefit over prednisone is it isn’t absorbed into systemic circulation and, therefore, has less systemic side effects.

DHEA (co-treat prednisone therapy with DHEA)

DHEA is an anabolic steroid produced naturally in our adrenal gland. It has been termed the “youth hormone” because it helps to keep us younger with less risk of developing the common degenerative diseases like diabetes, heart disease, and osteoporosis. Studies have shown serum levels of DHEA are significantly lower in patients with chronic inflammatory diseases and chronic prednisone treatment. Therefore, I commonly recommend patients receiving prednisone therapy also take DHEA as it can reduce the side effects caused by prednisone. (21)

Aminosalicylates

Aminosalicylates are aspirin-like anti-inflammatory drugs often used as the first-line treatment in early disease states of IBD. Sulfasalazine and mesalamine are more commonly used in the treatment and management of ulcerative colitis for inducing and maintaining controlled remission. Mesalamine (Canasa, Rowasa) is commonly used as a retention enema or suppository to treat proctitis (inflammation of the rectal pouch) and distal colitis. Blood tests to check liver and kidney function and blood counts to check white blood cells should be done every 3-6 months in patients being treated with these medications. Also, folic acid must be supplemented when using sulfasalazine as it inhibits the absorption of folic acid.

Generic Names of Aminosalicylates

  • balsalazide disodium
  • mesalamine
  • olsalazine sodium
  • sulfasalazine

Immunosuppressive Drugs

Immunosuppressive drugs such as 6-mercaptopurine (6-MP), azathioprine and Remicade are commonly used as second-level therapy in patients who are not well managed on just aminosalicylates and diet/nutritional intervention alone. These immunosuppressive drugs can help maintain a remission and reduce the dose of and reliance on corticosteroids. 6-MP and azathioprine have a longer history of use and are safer than Remicade (Infliximab). Remicade is still somewhat the “new kid on the block” and is used when “all else fails” or when progressive pathology is serious enough to warrant its use. Remicade has MANY side effects including cancer. But, it saves lives and reduces risks of serious complications when the time is right for its use.

 

This is Part 4 of a 5-part article including:

1. An Integrated Approach to Managing Inflammatory Bowel Disease

2. Diagnostic Evaluation of IBD

3. IBD Treatment: Remove the Obstacles to Cure

4. IBD Treatment: Quiet the Inflammation

5. IBD Treatment: Repair the Gut

(or, download the PDF of the entire article)

References

1. The Lancet Infectious Diseases. Volume 7, Issue 9, September 2007, 607-613

2. Gastroenterology.Volume 115, Issue 6, December 1998, 1405-1413

3. Inflamm Bowel Dis. 2005 Feb;11(2):178-84

4. World J Gastroenterol. 2009 Nov 28;15(44):5517-24

5. Inflamm Bowel Dis. 2008 Jun;14(6):738-43

6. World J Gastroenterol. 2008 Jan 21;14(3):331-7

7. Inflamm Bowel Dis. 2008 Jun;14(6):775-9

8. Eur J Gastroenterol Hepatol. 2001 Feb;13(2):93-5

9. Curr Pharm Des. 2009;15(18):2087-94

10. Int J Colorectal Dis. 2001 Apr;16(2):88-95

11. Curr Med Chem. 2006;13(28):3359-69

12. J Immunol. 2006 Mar 1;176(5):3127-40

13. Int J Colorectal Dis. 2001 Apr;16(2):88-95

14. Eur J Med Res. 1997 Jan;2(1):37-43

15. Nutrition. 2001 Jul-Aug;17(7-8):669-73

16. Cancer Epidemiol Biomarkers Prev. 2008 May;17(5):1136-43

17. Cochrane Database Syst Rev. 2007 Apr 18;(2):Crohn's disease006320

18. Clin Rheumatol. 2007 Mar;26(3):289-97

19. Clin Rheumatol. 1996 Jan;15 Suppl 1:62-66

20. Clin Rheumatol. 2007 Mar;26(3):289-97

21. Z Rheumatol. 2000;59 Suppl 2:II/108-18

22. World J Gastroenterol. 2007 May 28;13(20):2826-32

23. J Clin Gastroenterol. 2006 Mar;40(3):235-43

24. Adv Exp Med Biol. 1999;472:149-58

25. Dig Dis. 2009;27(4):450-4

26. Int J Med Microbiol. 2010 Jan;300(1):25-33

27. Dig Dis. 2009;27(3):412-7

28. Rev Recent Clin Trials. 2008 Sep;3(3):167-84

29. Aliment Pharmacol Ther. 2009 Oct 15;30(8):826-33

30. J Biol Chem. 2006 Aug 25;281(34):24449-54

31. Aliment Pharmacol Ther. 2009;30(8):826-33

32. Scand J Gastroenterol. 2008;43(7):842-8

33. Dig Dis Sci. 2000 Jul;45(7):1462-4

About the Writer

Dr. Patrick Donovan of TheDispensaryOnline.comDr. Donovan is a Naturopathic Physician, author, educator, and a professor of clinical medicine at Bastyr University's Natural Health Clinic. In 2010 he was voted by his professional peers as one of Seattle’s Top Doctors in the Seattle Metropolitan Magazine. Dr. Donovan writes and lectures on the transformational process of healing and believes a person’s healing journey is ultimately a quest for his/her identity, purpose and meaning. He has more than 35 years of patient care experience as a Registered Nurse (RN) and a Naturopathic Physician (ND), representing a wide range of clinical settings from hospital-based surgical and intensive care as a registered nurse to outpatient primary care as a physician.

Copyright 2011. The contents of this article may be reused, but must be reused in full (and full credit given to its authors). If you have specific questions, please contact us.

April 27th, 2011 by Dr. Patrick Donovan


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