IBD Patients Self-treating with Nonconventional Remedies.
Gastroenterologists should warn against using alternative approaches in lieu of prescribed medications.
An estimated 30-50%, and possibly 60%, of patients with inflammatory bowel disease (IBD), turn to complementary and alternative medicines (CAMs) to ease symptoms and exert more control over their treatment.
“Patients often see these as more natural and therefore safer and less toxic than prescribed medications,” Adam S. Cheifetz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, told AGA Reading Room. And since only half of patients volunteer CAM information, the onus is on physicians: “Ask all patients if they’re using any over-the-counter, under-the-counter, or non-conventional therapies,” he said. “Keep an open mind, but make sure [patients are taking the CAMs] as complementary agents in conjunction with medications and not as alternatives to prescribed medications.”
Very few studies have evaluated CAMs, and many of the studies were small, poorly designed, and uncontrolled, added Cheifetz, first author of a comprehensive 2017 overview of CAMs used by IBD and other chronic disease patients.
In addition, herbal preparations are unregulated and have perennially suffered from a lack of quality and content control — “There have been reports of some containing prescription drugs such as prednisone, for example.” Potential side effects and interactions with concomitant prescriptions are also a concern.
The lack of rigorously blinded and controlled trials has limited physician acceptance of CAMs in the age of evidence-based medicine, he said. “But physicians should be aware of at least the more commonly used remedies, such as the probiotic VSL#3 and curcumin.”
Broadly speaking, the CAM armamentarium of IBD patients extends beyond herbal agents and dietary supplements, and may include mind-body interventions such as prayer, mindfulness, tai chi, yoga, hypnosis, meditation, and biofeedback, as well as external treatments such as exercise, chiropractic, reflexology, acupuncture, and moxibustion; some CAM users are also turning to “energy medicine,” such as bioelectromagnetic-based therapies.
According to the overview by Cheifetz et al, predictors of CAM use include dissatisfaction with conventional therapies, female sex, higher education, use by friends or relatives, long-term disease progression, and prolonged steroid use. “Some patients perceive that their usual medications are having side effects or they’re not producing the desired response,” Cheifetz said.
In his own practice, he noted, he sometimes suggests a short trial of a CAM as a bridge between levels of IBD therapy. “If a patient is on 5 aminosalicylates or mesalamine and is as fully optimized as possible on those, we’ll discuss using VSL#3 or curcumin for a couple of weeks in the context of stepping up to biological therapy. I tell them if they don’t get better, we’ll move them up to a biologic. It gets them ready.”
COMPLEMENTARY AND ALTERNATIVE MEDICINES
CAMs appear to be used equally by patients with Crohn’s disease (CD) and ulcerative colitis (UC), but use varies geographically, with patients in California more likely to use nutritional supplements than their counterparts in Texas, where spiritual therapies are twice as common. And while some fear that CAM use may reduce medication compliance, a 2012 study by Adam Weizman et al found no difference between CAM users and non-users in adherence to prescribed IBD therapy.
The overview by Cheifetz’s group offers a roadmap to existing evidence on CAM therapies, addressing a range of lesser-used nonconventional therapies as well as the following four popular CAMs:.
– Probiotics are probably the CAMs most commonly used by IBD patients, and there is a small amount of evidence that VSL#3 may help patients with pouchitis and mild-to-moderate UC, Cheifetz said. Nonpathogenic strains of Escherichia coli have shown an effect in maintaining remission in patients with UC. In CD, one study found Lactobacillus and VSL#3 to be ineffective in preventing postoperative recurrence of severe disease, although some patients receiving early VSL#3 had reduced mucosal cytokines at 3 months.
– Curcumin/Turmeric: Similarly, there is some evidence that the phytochemical curcumin helps induce remission in patients with mild-to-moderate UC and incomplete response to 5 aminosalicylates, inducing remission in 54% of patients. Curcumin may also have some value as remission maintenance therapy in quiescent UC, according to Japanese researchers.
– Fish Oil: Large well-designed trials in CD have been negative, finding no benefit versus placebo for preventing CD relapse, while one small study showed it reduced the rate of relapse in high-risk CD patients, Cheifetz noted. Results in UC have also been disappointing, however, with the largest studies of patients in remission showing no statistically significant differences in the rates of relapse or macroscopic and histologic appearance. One analysis, however, found that fish oil exerted a modest corticosteroid-sparing effect in active disease but had no benefit for maintenance therapy. The review authors noted that fish oil’s interaction with immunomodulatory and biologic therapies has not been studied.
– Cannabis: Increasing numbers of patients are choosing medical marijuana. “There are a few small studies in which quality of life and some symptoms improved, but cannabis definitely did not induce remission or objectively reduce inflammation,” he said. In one 21-patient study, for example, cannabis led to significant steroid-free-clinical improvement without any side effects. “But akin to smoking tobacco, one study suggested that smoking marijuana might increase the risk of needing surgery”.
In the review, Cheifetz and colleagues urged physicians to explore the mechanism and evidence behind CAMs so they can offer rational advice to patients. The team stressed the need to ask patients what agents they are using and whether they are using them as adjuncts only: “Although CAMs could be used to supplement conventional IBD therapy, further research is needed to validate these approaches.”