21 Jun 2017

Study probes complementary and alternative medicine use for bowel disease

Dr Raffi Luber, co-
author on a study of
IBD & CAM therapy
by Anne Crawford

Physicians treating patients for inflammatory bowel diseases (IBD) are occasionally asked about the use of complementary and alternative medicines (CAMs) but often have limited knowledge of the therapies and can be quick to dismiss their efficacy.

A study by researchers in the Department of Gastroenterology at the Alfred Hospital has reviewed the available evidence for the most commonly used and discussed CAMs so informed advice can be offered to patients wanting to know about them.

The study was supervised by Professor Peter Gibson, Head of Gastroenterology at the Alfred and Central Clinical School, who worked with Gastroenterology Clinical Research Fellow Dr Raphael Luber, in conjunction with researchers at the Beth Israel Deaconess Medical Center in Boston, Massachusetts.

“Physicians traditionally know little about the realm of CAMs, despite the immense popularity among our patients. This review aimed to demystify this area by presenting the commonly used CAMs in IBD, their available evidence or lack thereof, in order to help us guide our patients,” Dr Luber said.

Published in the journal ‘Gastroenterology’, the review found that more than half of patients with IBD have used CAMs at some stage of their disease although they often did not divulge this to their treating doctor, fearing a negative response. Most gastroenterologists however, believed that CAMs could be used to supplement the treatment of IBD. The most commonly used CAMs include probiotics, herbs, vitamins, fish oil and mind-body techniques such as acupuncture.

The review found that few studies had evaluated the therapies, and many of these had small sample sizes or were uncontrolled. It comments that it is challenging to design rigorous, randomised, placebo-controlled trials within this field, partly due to problems of quality control for herbal preparations and adequate blinding for mind-body interventions.

It includes a long list of therapeutic substances found in a Google search that claim efficacy in patients with IBD – ranging from Vitamin C to oxygen therapy to yogurt enemas. Most had little or no evidence, it found. Tables of randomised controlled trials are included.

Some of the more common CAMS are discussed in more detail. In brief:
  • Marijuana, used more commonly in patients with IBD than in the general population, may reduce symptoms but there was no evidence that it positively alters the disease course and, with associated unpredictable psychoactive effects, the researchers could not recommend its use to treat IBD. More data from clinical trials are needed.
  • Curcumin, the major active ingredient of turmeric, could be considered as a supplementary treatment in select patients with mild to moderate ulcerative colitis, and as supplementary therapy for patients currently in remission on optimised mesalamine.
  • Although there were biologic mechanisms by which fish oil could reduce inflammation and positive results from animal studies, there have been insufficient findings from large studies of patients that fish oil maintains remission in patients with ulcerative colitis (UC) or Crohn’s disease (CD). At best, fish oil could be regarded as a supplement that at least does no harm.
  • Some herbs warranted further study. Promising herbs include aloe vera, which was found 12 years ago to provide convincing benefits, without side effects, to patients with active UC in a good quality study.
  • Probiotics, most commonly bacteria and/or yeast, are ubiquitous in gastroenterology practice and are the most-used complementary therapy by patients with IBD. Little is known about the mechanisms of beneficial effects of probiotics, but these are likely to be immunomodulatory and anti-inflammatory. The evidence suggests some probiotics may have an adjunct role in patients with UC, but not CD.
  • Acupuncture and moxibustion, traditional Chinese medicine techniques using respectively needles and heat therapy and herbs, have had impressively positive results from human studies but these carry multiple limitations. Evidence-based clinical application should be restricted to patients receiving no other therapy, who are unwilling or unable to be treated with conventional agents.
  • Patients with IBD have higher rates of anxiety and depression. There are links between psychologic stress and IBD flares. But while cognitive therapies including relaxation programs, psychodynamic therapies, hypnosis, yoga and comprehensive mind-body programs increase quality of life, psychological benefits and in some cases reduce symptoms such as pain in patients with UC or CD, the strategies have few effects on disease activity itself.
  • Mild to moderate exercise programs provide multiple benefits to patients with IBD with at least mild inflammation. Exercise does not appear to have detrimental effects on disease activity.
The paper urges physicians to explore the use of CAMs with their patients and ensure that they are used safely, although with the caveat never as an alternative or replacement for accepted and well-studied medical therapies. Further research was needed to validate these approaches, it concluded.

Cheifetz AS, Gianotti R, Luber R, Gibson PR. Complementary and Alternative Medicines Used by Patients With Inflammatory Bowel Diseases. Gastroenterology. 2017 Feb;152(2):415-429.e15. doi: 10.1053/j.gastro.2016.10.004. Epub 2016 Oct 12.

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