Crohn’s Disease

Overview: Crohn’s Disease

• Crohn's disease (CD) and ulcerative colitis (UC) are thought to result from inappropriate activation of the mucosal immune system, facilitated by regulatory defects in the mucosal immune response and failure of the mucosal bar-rier that separates immune response cells from the con-tents of the intestinal lumen.

• The normal gut flora act as a trigger for the inflammatory response and appear to play a central role in pathogenesis. In both diseases, increased numbers of surface-adherent and intracellular bacteria have been observed in mucosal biopsies.

• Patients with UC and CD share immunologic abnormalities that are common among patients with other types of autoimmune disorders, including up-regulation of subtype 17 helper T-cell (Th17)-positive lymphocytes and the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1), IL-6, and IL-23, accompanied by down-regulation of regulatory T cells and the antiinflammatory cytokine IL-1 receptor antagonist (ILlra).

Important points to consider

• Zinc competes with copper, iron, calcium, and magnesium for absorption. When administering high doses of zinc, consider administering a multimineral at a separate time of day. Zinc is absorbed best if not taken at the same time as copper, magnesium, or iron.

• Some supplements may be strongly contraindicated because of potential toxicity: the strongest evidence exists for melatonin in Crohn disease, glutamine in ulcerative colitis, and Echinacea in patients taking immunosuppressants.

• Always ask patients about the effect of antibiotics, including those drugs used for unrelated illnesses, on their gastrointestinal symptoms. Improvement of symptoms during antibiotic therapy y may be an indication to use that antibiotic empirically during an exacerbation of symptoms. Aggravation of symptoms during antibiotic therapy may be an indication to avoid the specific antibiotic and employ probiotics.

• The efficacy of 5-aminosalicyclic acid (5-ASA) derivatives in inducing remission of inflammatory bowel disease can be enhanced by fish oils supplying 4000mg of eicosapentaenoic acid plus docosahexaenoic acid per day and by probiotics (VSL-3, two packets a day, or Saccharomyces boulardii, 250 mg three times a day).

Prevention Prescription

• Observational studies suggest that diet influences the risk of developing IBD. The following dietary changes are associated with reduced risk:

• High-fiber diet (at least 25 g per day) Limited use of foods with added sugar or fat and avoidance of vegetable oils except olive oil Limited consumption of beef or poultry (UC) Omega-3 fatty acids from animal and vegetable sources should supply at least 1% of calories, and omega-6 fatty acids should supply no more than 7% of calories. For patients with IBD in remission, prevention of relapse may benefit from the following interventions:

• Prolonged use of 5-aminosalicylic acid (5-ASA) derivatives plus folate, typically 1 mg/day Along with a 5-ASA derivative, also prescribe Saccharomyces boulardii, 1000 mg per day.

• Constipation is a significant side effect. Additional evidence-based interventions for relapse prevention include the following:

• Vitamin D: 1200 units per day for CD Curcumin: 1000 to 1800 mg twice a day with meals for patients with UC. These interventions not only reduce the risk of relapse but also may reduce the risk of colon cancer. For maintenance of remission in patients with UC, a high-fiber, low-meat diet with limited alcohol, supplemented with fish oils supplying approximately 5000 mg/day of omega-3 fatty acids (main side effect is diarrhea) and the probiotic VSI.-3

• A specific food exclusion diet, individually tailored, avoidance of tobacco exposure, and reduced consumption of sucrose for maintenance of remission in patients with CD Folic acid, vitamin B, and vitamin B, at doses that keep circulating homocysteine low, to prevent thrombotic complications

• Vitamin D: 1200 units/day, to prevent bone loss and perhaps relapse

Integrative therapeutics review

All patients with inflammatory bowel disease (IBD) should be under the care of a gastroenterologist for regular endoscopic examination and prescription of appropriate drug therapy. The main role of the integrative practitioner is to help patients develop effective self-management strategies and enhance conventional treatment with an individualized nutritional prescription and the use of nutritional and botanical supplements.

Laboratory Tests

• Certain laboratory tests are useful for fulfilling this role effectively. Commonly used tests include complete blood count, erythrocyte sedimentation rate, C-reactive protein, and serum albumin. Useful markers of nutritional status in IBD also include plasma zinc and homocysteine, serum and urine magnesium, serum iron, ferritin and transferrin, and 25-OH vitamin D. In steroid-treated patients with refractory disease, serum dehydroepiandrosterone sulfate (DHEA-S) may be useful. Patients with recent onset, relapse, or exacerbation of IBD-especially those with diarrhea-should undergo stool testing for parasites, pathogenic bacteria, Clostridium difficile toxins, and yeast.

Self-Management

• Spend an office visit ensuring that patients can recognize the symptoms of relapse and have a plan for controlling them.

• Use a mutually acceptable treatment protocol for the patient to initiate at the onset of a relapse.

Nutrition

• Avoid sucrose and symptom-provoking foods.

• As described earlier, the Specific Carbohydrate Diet, an exclusion diet, or a defined formula diet may help relieve symptoms and may help induce or maintain remission, especially in patients with Crohn's disease (CD).

• Balance dietary restrictions with the need for adequate macronutrient intake.

• Replace vegetable oils with olive, flaxseed oil, or coconut oil (1 to 2 tablespoons/day).

• Recommend oat bran, 60 g/day, for patients with mild-to-moderate ulcerative colitis (UC).

Supplements

• Folate: 1 mg/day or more especially for patients with high homocysteine or taking 5-ASA derivatives

• Vitamin B 1 mg/month for patients with ileitis or previous ileal resection. receiving folic acid, or with high

  homocysteine

• Vitamin B: 10 to 20 mg/day, especially for patients with high homocysteine or taking high-dose folic acid or with urolithiasis

• Vitamin D: 1000 units/day or more to maintain levels of 25-OH vitamin D at 40 ng/ml.

• Zinc: 25 to 200 mg/day to maintain plasma zinc at more than 800 mg/L.

• Calcium: 1000 mg/day for patients taking steroids or with low dietary calcium

• Selenium: 200 mcg/day for patients with ileal resection or on liquid formula diets

• Magnesium citrate: 150 to 900 mg/day for patients with urolithiasis. Watch out for magnesium's laxative effect.

• Chromium: 600 mcg/day for patients with steroid-induced glycemia

• Fish oils supplying 4000 to 5000 mg/day of omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid) for patients with UC. Fish oils may cause diarrhea. Most fish oil capsules are only 50% omega-3 fatty acids. N-Acetylglucosamine (NAG): 3000 to 6000 mg/day

• Prebiotic oligosaccharides: approximately 10g per day for UC. They can cause distention and flatulence.

Biologic Agents

• VSL-3: one sachet twice a day for patients with mild-to-moderate UC who are not sensitive to corn, the growth medium used. Any probiotic may aggravate bowel symptoms in patients with IBD.

• Saccharomyces boulardii: 250 mg three times daily or 500 mg twice daily for patients with chronic stable disease or to help maintenance of remission in patients not shown to be sensitive to yeast. S. boulardii may cause constipation.

• DHEA: 200 mg/day for patients with refractory disease and low DHEA-S

Botanicals

• Boswellia serrata gum resin: 350 mg three times daily for patients with UC who are intolerant of 5-ASA derivatives Curcumin: 1000 mg twice daily with meals

• Mastic gum: 1000 mg twice daily for patients with CD

• Aloe vera gel: 100 ml. bid for patients with UC Aloe may cause diarrhea.

Pharmaceuticals

• 5-ASA derivatives for induction of remission in mild-to-moderate colitis and for maintenance of remission

• Antibiotics for acute exacerbations of CD or UC or perianal disease

• Glucocorticoids for induction of remission in severe disease

• 6-Mercaptopurine or azathioprine for steroid-dependent IBD or for maintenance of remission when 5-ASA derivatives fail

• TNF-alpha blockers. For patients with severe CD, initiating pharmaceutical therapy with immunosuppressants and TNF-alpha blockers (step-down therapy) produces superior long-term results to initiating therapy with steroids and 5-ASA derivatives (step-up therapy). None of these studies included dietary interventions, which are of proven value in CD.

Surgical Resection

• For patients with colonic dysplasia or for those who fail to respond to medical management

  Postsurgical recurrence rate is high for CD, and pouchitis is a frequent complication of ileal pouch-anal anastomosis for UC.

Key Web Sources

• http://www.nutritionworkshop.com/medication-sandsupplementsinteractions/login.php

• www.ccfa.org

• www.breakingtheviciouscycle.info

• http://www.digestivewellness.com

• http://www.imixnaturals.com/index.aspm

• www.ovamed.org