Complementary and alternative medicine in inflammatory bowel disease patients: frequency and risk factors

Cannabis Use in Patients With Inflammatory Bowel Disease Following Legalization of Cannabis in Canada

Background

Cannabis is used by patients with Crohn's disease (CD) and ulcerative colitis (UC) as an alternative to, or in combination with, conventional therapies to treat symptoms such as abdominal pain, poor sleep, and reduced appetite. The clinical efficacy of cannabis for these disorders is controversial, with some studies showing harmful outcomes associated with its use. Previous studies suggest that cannabis is used by ~12% of patients with UC and ~16% of patients with CD in the USA despite legal prohibition.

Methods

We conducted a prospective cohort study of adult patients with inflammatory bowel diseases (IBD) followed in a Canadian tertiary care center. Patients completed an online 40-question survey that included demographics, IBD disease history, cannabis use, and the Short Inflammatory Bowel Disease Questionnaire (SIBDQ).

Results

Completed surveys were obtained from 254 participants (148 with CD, 90 with UC, and 16 with indeterminate colitis). Recent cannabis use was reported by 41% of CD and 31% of UC participants. Interestingly, only 46% of participants who used cannabis discussed their use with their physician. Participants who recently used cannabis reported more abdominal pain, poor appetite, and flatulence, and importantly this was associated with lower SIBDQ scores (recent use 37 vs non-recent use 40).

Conclusions

Cannabis use among patients with IBD has more than doubled since its legalization. Cannabis use is associated with worse abdominal symptoms and quality of life. Physicians should inquire about cannabis use and optimize symptom control with evidence-based therapies.

Patient, Parent, and Provider Perceptions of Barriers to Pediatric Inflammatory Bowel Disease Care

Objectives

Children with inflammatory bowel disease (IBD) have a significant life-long burden as a result of disease, impacted by environmental and individual barriers. Successful health system interventions require a comprehensive approach, informed by various stakeholders. The main objective was to identify health system barriers and potential solutions from existing patients, families, and providers via focus groups.

Methods

Participants for the focus groups were existing English-speaking patients (ages 9-18) with IBD, their caregiver(s), and providers including multiple professions (eg, physician, nurse, pediatrician, social worker, care coordinator, scheduler, and psychologist). Separate focus groups were led by experienced personnel for parents, children, and providers, using a standardized interview guide. Sessions were recorded, transcribed, and verified. Using content analysis, we systematically classified data through coding and identified themes.

Results

Focus groups comprised (a) 3 patient groups (n = 20, 50% female, including 2 younger; mean age = 11.4 ± 1.5 years) and 1 older group (mean age = 15.6 ± 1.3 years), (b) 3 parent groups (n = 24, 83% female), and (c) 2 multidisciplinary provider groups (n = 19). Families shared several common concerns with providers (eg, school, care delay, psychosocial, and financial) but varied on specifics. Some barriers may be addressable through family or staff education, improved communication (eg, care delay/ access, transition), or training (eg, labs and diet), while others may require change at an institutional or policy level (eg, insurance).

Conclusions

This qualitative analysis identified several barriers to IBD care, some shared, some unique to patients, parents, and providers, highlighting the importance of obtaining multiple stakeholder perspectives when exploring barriers to care.

Herb-Drug Interaction in Inflammatory Diseases: Review of Phytomedicine and Herbal Supplements

Many people worldwide use plant preparations for medicinal purposes. Even in industrialized regions, such as Europe, where conventional therapies are accessible for the majority of patients, there is a growing interest in and usage of phytomedicine. Plant preparations are not only used as alternative treatment, but also combined with conventional drugs. These combinations deserve careful contemplation, as the complex mixtures of bioactive substances in plants show a potential for interactions. Induction of CYP enzymes and pGP by St John's wort may be the most famous example, but there is much more to consider. In this review, we shed light on what is known about the interactions between botanicals and drugs, in order to make practitioners aware of potential drug-related problems. The main focus of the article is the treatment of inflammatory diseases, accompanied by plant preparations used in Europe. Several of the drugs we discuss here, as basal medication in chronic inflammatory diseases (e.g., methotrexate, janus kinase inhibitors), are also used as oral tumor therapeutics.

Comprehensive study on the administrative, economic, regional, and regulatory prospects of complementary and alternative medicine (CAM) in inflammatory bowel disease (IBD)

Introduction: Due to the high cost, low effectiveness, and adverse effects plus the life-long nature of inflammatory bowel disease (IBD), and misconception on safety, efficacy, and cost-effectiveness of complementary and alternative medicine (CAM), the market demand for CAM has risen over the past decades. A critical review of patients' and physicians' attitudes, market drivers, economic aspects, regulatory roles, and regional distribution is lacking.Areas covered: Through relevant databases, the existing English language literature concerning the association of CAM use with IBD was collected over the past two decades. Data was then analyzed, comprehensively summarized in tables/figures, and justified concerning administrative, organizational, regional, economic, and regulatory perspectives.Expert opinion: Although CAM utilization is more prevalent among younger, female, and high-educated IBD patients, issues concerning weak study designs, limited-time period/regional distribution of recent surveys, and lack of economic evaluations on CAM make it entirely unfeasible to draw a firm conclusion. Regulators are lagging in meeting the dire need of IBD patients, especially the elderly. Lack of legislation regarding registration, sales monitoring, licensing, insurance coverage, efficacy/safety assessments, post-marketing surveillance, quality assurance, and reference pricing alongside the limited support for CAM research are the main matters that should be urgently addressed.

Electroacupuncture preserves intestinal barrier integrity through modulating the gut microbiota in DSS-induced chronic colitis

AIMS

Electroacupuncture (EA) at ST36 has been verified to ameliorate experimental acute colitis. However, the effect of EA on chronic colitis and its mechanism has not yet been explored. This study aimed to assess the protective effect of EA against chronic colitis and the related mechanisms.

MAIN METHODS

Chronic colitis was induced by dextran sulfate sodium (DSS) in C57BL/6 mice, and EA was applied throughout the entire experiment. Colonic inflammation and intestinal barrier integrity were evaluated. Alterations in the gut microbiota were analyzed by 16S rRNA gene sequencing. The fecal microbiota transplantation (FMT) experiment was used to further confirm the effect of the gut microbiota on the barrier protective effect of EA. The potential molecular mechanisms were explored by western blotting.

KEY FINDINGS

(1) EA lowered the disease activity index (DAI) and histological scores, decreased the levels of TNFα, IL1β, IL6 and iNOS, and increased the IL10 level in DSS-induced chronic colitis. (2) EA upregulated the protein expression of ZO-1, Occludin, E-Cadherin and mucin2 (MUC2), reduced the apoptosis and proliferation of intestinal epithelial cells (IECs) and intestinal permeability. (3) EA enhanced the gut microbiota diversity and restored the community structure. (4) Both the low-frequency EA (LEA) FMT and high-frequency EA (HEA) FMT maintained the intestinal barrier integrity. (5) EA promoted activation of the mitogen activated protein kinase (MAPK) signaling pathway.

SIGNIFICANCE

EA can relieve chronic experimental colitis, and this effect may depend on activation of the MAPK signaling pathway through modulation of the gut microbiota to preserve the intestinal barrier.

Experiences With Traditional Chinese Medicine Among Patients With Inflammatory Bowel Disease: A Qualitative Study

Despite the increasing number of inflammatory bowel disease (IBD) patients using traditional Chinese medicine (TCM), relatively few studies have examined their experiences with TCM in the Chinese healthcare context. The aim of this study was to explore these experiences from the perspective of IBD patients. Adopting a qualitative descriptive method, IBD patients from several comprehensive hospitals in Hangzhou, Zhejiang were recruited through purposive sampling. Data were collected using semistructured interviews and analyzed by a conventional content analysis method. The results are presented thematically. Fourteen IBD patients participated in the study. They often used TCM, such as Chinese herbal medicine, retention enemas of Chinese medicine, and acupuncture, as a complementary therapy instead of as an alternative to conventional therapies. Three themes emerged from the analysis: triggers for initiating TCM, the experienced efficacies of TCM, and disturbances caused by TCM use. The IBD patients initiate TCM treatment due to the unsatisfactory effects of conventional therapies and TCM culture. However, the efficacies of TCM are subjective and slow acting and vary across individuals. There are communication gaps between physicians and patients concerning TCM. Thus, healthcare professionals are encouraged to gain more knowledge on these therapies and employ a participatory decision-making style based on this understanding.

Studying the Influence of Apple Peel Polyphenol Extract Fortification on the Characteristics of Probiotic Yoghurt

The aim of the current study was to evaluate the effect of apple peel polyphenol extract (APPE) on the physicochemical and microbiological properties of probiotic yoghurt. Five concentrations of APPE were added in probiotic yoghurt as: (1) CTL, control without APPE; (2) AE1, addition of 1% APPE; (3) AE2, addition of 2% APPE; (4) AE3, addition of 3% APPE; (5) AE4, addition of 4% APPE; and (6) AE5, addition of 5% APPE. The prepared probiotic yoghurt was stored at 4 °C for 21 days and analyzed for physicochemical and microbiological properties. The initial viable count of L. bulgaricus, S. thermophilus, B. lactis and L. acidophilus were similar in all yoghurt samples at day 1. The maximum viability loss of probiotics was observed in CTL (p < 0.05). The lowest viability loss of probiotics was observed in AE5 samples (p < 0.05). The acidity, water holding capacity and viscosity were increased with the addition of APPE. No significant effects were observed on milk fat and total solid contents of probiotic yoghurt with the addition of APPE. The total phenolic contents of probiotic yoghurt increased significantly as 0.59, 0.71, 0.97, 1.18, 1.35 in AE1, AE2, AE3, AE4 and AE5, samples respectively. It was observed that AE3 and AE4 samples had better taste, flavour and colour with good texture. The survival of probiotics and antioxidant activity of the yoghurts were enhanced with the addition of APPE. In conclusion, apple peels could be successfully used as prebiotic in yoghurt with increased viable counts of probiotics.

Complementary and alternative medicine in patients with inflammatory bowel disease: A survey performed in a tertiary center in Chile

OBJECTIVES

The aim of this study was to assess the type and prevalence of complementary and alternative medicine (CAM) use in patients with inflammatory bowel disease (IBD) who are treated at our center.

DESIGN

Observational, cross-sectional questionnaire-based study that included patients from the IBD program of our center.

SETTING

Tertiary clinical center in Santiago, Chile.

MAIN OUTCOME MEASURES

Types of CAM being used by patients with IBD.

RESULTS

A total of 200 patients were included, 68% ulcerative colitis, 29% Crohn's disease, and 3% non-classifiable IBD. Overall, 25% of the patients reported current use of CAM, 30% reported using in it the past, and 45% indicated that they had never used it before. The use of CAM was recommended in 20% of the patients by other healthcare professionals and in 10% of the patients by the gastroenterologist. Forty-nine percent of the patients informed the gastroenterologist that they were using CAM. Overall, 86% of the patients did not modify the conventional medical treatment (CMT). None of the patients who were using curcumin, homeopathic medicine, acupuncture or biomagnetism modified the CMT.

CONCLUSIONS

The type of CAM being used plays an important role when the patient makes the decision to inform the gastroenterologist. Other healthcare professionals play an important role in providing the advice to start CAM. Gastroenterologists must be aware of the high prevalence of CAM use in IBD patients, actively ask about CAM use and guide the patients who want to use CAM in a responsible and safe manner.

Use of Complementary and Alternative Medicine in Inflammatory Bowel Disease Around the World

Use of complementary sand alternative medicine (CAM) is common among patients with inflammatory bowel disease (IBD). CAM can be broadly categorized as whole medical systems, mind-body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies. Most do not use it to treat IBD specifically, and most take it as an adjunct to conventional therapy not in place of it. However, patients are frequently uncomfortable initiating a discussion of CAM with their physicians, which may impact adherence to conventional therapy. A greater emphasis on CAM in medical education may facilitate patient-physician discussions regarding CAM.

The who-when-why triangle of CAM use among Portuguese IBD patients

BACKGROUND

The use of complementary and alternative medicines is increasing among chronic patients, particularly those afflicted with inflammatory bowel diseases.

AIM

This study aimed to address the prevalence of complementary and alternative medicines use among Portuguese inflammatory bowel diseases' patients.

METHODS

Patients were invited to fill an anonymous questionnaire concerning the use of complementary and alternative medicines.

RESULTS

Thirty-one per cent of the patients reported having used complementary and alternative medicines in the past, whereas 12% were using them by the time the questionnaire was administered. Fifty-nine per cent of the users did not share this information with their physician, whereas 14% and 8% discontinued their medication and periodical examination, respectively. Steroids prescription (OR=2.880) and a higher instruction level (OR=3.669) were predictors of complementary and alternative medicines use in this cohort.

CONCLUSIONS

Roughly a third of Portuguese IBD patients had used CAM. Steroid treatment and an academic degree are associated with CAM use. Given the potential side effects and interactions, patient information about the benefits and limitations of conventional and complementary treatments should be reinforced.

Complementary and Alternative Medicines Used by Patients With Inflammatory Bowel Diseases

Patients and physicians often have many questions regarding the role of complementary and alternative medicines (CAMs), or nonallopathic therapies, for inflammatory bowel diseases (IBDs). CAMs of various forms are used by more than half of patients with IBD during some point in their disease course. We summarize the available evidence for the most commonly used and discussed CAMs. We discuss evidence for the effects of herbs (such as cannabis and curcumin), probiotics, acupuncture, exercise, and mind-body therapy. There have been few controlled studies of these therapies, which have been limited by their small sample sizes; most studies have been uncontrolled. In addition, there has been a lack of quality control for herbal preparations. It has been a challenge to design rigorous, randomized, placebo-controlled trials, in part owing to problems of adequate blinding for psychological interventions, acupuncture, and exercise. These barriers have limited the acceptance of CAMs by physicians. However, such therapies might be used to supplement conventional therapies and help ease patient symptoms. We conclude that physicians should understand the nature of and evidence for CAMs for IBD so that rational advice can be offered to patients who inquire about their use. CAMs have the potential to aid in the treatment of IBD, but further research is needed to validate these approaches.

Apple peel polyphenols: a key player in the prevention and treatment of experimental inflammatory bowel disease

Diets rich in fruits and vegetables may reduce oxidative stress (OxS) and inflammation via several mechanisms. These beneficial effects may be due to their high polyphenol content. The aims of the present study are to evaluate the preventive and therapeutic aspects of polyphenols in dried apple peel powder (DAPP) on intestinal inflammation while elucidating the underlying mechanisms and clinical benefits. Induction of intestinal inflammation in mice was performed by oral administration of the inflammatory agent dextran sulfate sodium (DSS) at 2.5% for 10 days. Physiological and supraphysiological doses of DAPP (200 and 400 mg/kg/day respectively) were administered by gavage for 10 days pre- and post-DSS treatment. DSS-mediated inflammation caused weight loss, shortening of the colon, dystrophic detachment of the epithelium, and infiltration of mono- and poly-morphonuclear cells in the colon. DSS induced an increase in lipid peroxidation, a down-regulation of antioxidant enzymes, an augmented expression of myeloperoxidase (MPO) and cyclooxygenase-2 (COX-2), an elevated production of prostaglandin E2 (PGE2) and a shift in mucosa-associated microbial composition. However, DAPP normalized most of these abnormalities in preventive or therapeutic situations in addition to lowering inflammatory cytokines while stimulating antioxidant transcription factors and modulating other potential healing pathways. The supraphysiological dose of DAPP in therapeutic situations also improved mitochondrial dysfunction. Relative abundance of Peptostreptococcaceae and Enterobacteriaceae bacteria was slightly decreased in DAPP-treated mice. In conclusion, DAPP exhibits powerful antioxidant and anti-inflammatory action in the intestine and is associated with the regulation of cellular signalling pathways and changes in microbiota composition. Evaluation of preventive and therapeutic effects of DAPP may be clinically feasible in individuals with intestinal inflammatory bowel diseases.

Challenges and opportunities in the treatment of ulcerative colitis

Ulcerative colitis (UC) is an inflammatory destructive disease of the large intestine occurred usually in the rectum and lower part of the colon as well as the entire colon. Drug therapy is not the only choice for UC treatment and medical management should be as a comprehensive whole. Many synthetic drugs are available for the treatment of UC like 5-aminosalicylic acid, oral or systemic corticosteroids, immunomodulator, etc. but these drugs are associated with many serious side effects after long term use or have certain disadvantage or not suitable for the use in some patients. In short synthetic drugs have many disadvantages and for this reason effective and safe alternative drug treatment for the UC is the challenge. Herbal drugs are found to be very promising results of the treatment of UC and enzymatic level. Researchers explored many herbal drugs for the treatment and even many more may found effective in the treatment of UC. At this point we feel herbal medicine is the better alternative for the treatment of UC.

Doctor communication quality and Friends' attitudes influence complementary medicine use in inflammatory bowel disease

AIM: To examine the frequency of regular complementary and alternative therapy (CAM) use in three Australian cohorts of contrasting care setting and geography, and identify independent attitudinal and psychological predictors of CAM use across all cohorts.

METHODS: A cross sectional questionnaire was administered to inflammatory bowel disease (IBD) patients in 3 separate cohorts which differed by geographical region and care setting. Demographics and frequency of regular CAM use were assessed, along with attitudes towards IBD medication and psychological parameters such as anxiety, depression, personality traits and quality of life (QOL), and compared across cohorts. Independent attitudinal and psychological predictors of CAM use were determined using binary logistic regression analysis.

RESULTS: In 473 respondents (mean age 50.3 years, 60.2% female) regular CAM use was reported by 45.4%, and did not vary between cohorts. Only 54.1% of users disclosed CAM use to their doctor. Independent predictors of CAM use which confirm those reported previously were: covert conventional medication dose reduction (P < 0.001), seeking psychological treatment (P < 0.001), adverse effects of conventional medication (P = 0.043), and higher QOL (P < 0.001). Newly identified predictors were CAM use by family or friends (P < 0.001), dissatisfaction with patient-doctor communication (P < 0.001), and lower depression scores (P < 0.001).

CONCLUSION: In addition to previously identified predictors of CAM use, these data show that physician attention to communication and the patient-doctor relationship is important as these factors influence CAM use. Patient reluctance to discuss CAM with physicians may promote greater reliance on social contacts to influence CAM decisions.

Herbal medicines for the treatment of functional and inflammatory bowel disorders

In many parts of the world, there continues to be a long-standing tradition of prescribing herbal products for a range of gastrointestinal conditions. Scientific evidence supporting the use of all herbal preparations is imperfect, however, and available studies are plagued by methodological limitations. For functional gastrointestinal disorders, there is limited evidence supporting the use of some well-characterized preparations. A number of herbals have immunomodulatory activity, and in inflammatory bowel disease there are limited positive placebo-controlled trials; other studies used active controls with suboptimal doses of the comparators. Like all drugs, herbals can lead to serious adverse events (eg, hepatic failure). Quality control is a serious issue to consider when prescribing herbal medicines. Many herbal preparations are marketed without evidence for stringent adherence to good manufacturing practice guidelines. Unpredictable environmental conditions may affect the composition and the concentration of the active ingredients of plant extracts. Further, commercial herbal products usually combine a variable plethora of chemical families with possible medicinal utility. While some of these ingredients might be of benefit, the concentration and dose of these constituents needs to be closely monitored. Physicians and regulators need to remain very cautious about the use of herbal remedies. Appropriate scientific evidence for the claimed clinical benefits should become mandatory worldwide, and the standards for production and safety monitoring should comply with established standards for chemically defined products. If these principles were adopted, the full value of herbal remedies may come to light, particularly as the individually bioactive compounds present in these preparations become recognized.

Clinical characteristics and treatment of inflammatory bowel disease: A comparison of Eastern and Western perspectives

Inflammatory bowel disease (IBD) is a chronic, relapsing intestinal inflammatory disorder with unidentified causes. Both environmental factors and genetic aspects are believed to be crucial to the pathogenesis of IBD. The incidence and prevalence of IBD have recently been increasing throughout Asia, presumably secondary to environmental changes. This increasing trend in IBD epidemiology necessitates specific health care planning and education in Asia. To this end, we must gain a precise understanding of the distinctive clinical and therapeutic characteristics of Asian patients with IBD. The phenotypes of IBD reportedly differ considerably between Asians and Caucasians. Thus, use of the same management strategies for these different populations may not be appropriate. Moreover, investigation of the Asian-specific clinical aspects of IBD offers the possibility of identifying causative factors in the pathogenesis of IBD in this geographical area. Accordingly, this review summarizes current knowledge of the phenotypic manifestations and management practices of patients with IBD, with a special focus on a comparison of Eastern and Western perspectives.

Predictive factors of complementary and alternative medicine use for patients with inflammatory bowel disease in Korea

OBJECTIVES

The aim of this study was to assess characteristics and predictive factors of complementary and alternative medicine (CAM) use for patients with inflammatory bowel disease (IBD) in Korea.

DESIGN

Prospective, questionnaire based study for patients with IBD in Korea.

SETTING

Six university hospitals and one primary IBD clinic.

MAIN OUTCOME MEASURE

Overall characteristics and predictors of CAM use were compared between CAM users and non-users.

RESULTS

During the study period, 366 patients with IBD (ulcerative colitis=228, Crohn's disease=138) completed the full questionnaire; 29.5% (n=108) reported CAM use and 70.5% (n=258) reported no CAM use after diagnosis of IBD. In total, 64.0% were male, the mean patient age was 42.3±15.5 years, and the mean duration of IBD was 5.5±5.8 years. Using logistic regression analysis, university education (p=0.040), higher income levels (p=0.009), and longer duration of IBD (p=0.003) were found to be independent predictors of CAM use. Among CAM users, 65% of CAM was attained within 2 years of IBD diagnosis and only 28.7% discussed CAM use with their physician. Furthermore, 13.9% of CAM users discontinued conventional IBD therapy while using CAM.

CONCLUSIONS

The overall use of CAM in Korea was comparable with those in the West. Physicians should be aware of the high prevalence of CAM use by patients with IBD, especially among those with higher education levels, higher income levels, and longer IBD duration. Furthermore, physicians should ask about CAM use, and help their IBD patients make a more informed choice about CAM use.

Systematic review: the efficacy of herbal therapy in inflammatory bowel disease

BACKGROUND

Complementary and alternative medicine (CAM), particularly herbal therapy, is widely used by patients with inflammatory bowel disease (IBD) but controlled data are limited.

AIM

To systematically review the literature on the efficacy of herbal therapy in the treatment of ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

Publications in English and non-English literatures (MEDLINE, EMBASE, EBM Reviews, AMED, Global Health) were searched from 1947 to 2013 for controlled clinical studies of herbal therapy in IBD. Outcome measures included response and remission rates.

RESULTS

Twenty-one randomised controlled trials (14 UC; 7 CD) including a total of 1484 subjects (mean age 41, 50% female) were analysed. In UC, aloe vera gel, Triticum aestivum (wheat grass juice), Andrographis paniculata extract (HMPL-004) and topical Xilei-san were superior to placebo in inducing remission or response, and curcumin was superior to placebo in maintaining remission; Boswellia serrata gum resin and Plantago ovata seeds were as effective as mesalazine, whereas Oenothera biennis (evening primrose oil) had similar relapse rates as omega-3 fatty acids in the treatment of UC. In CD, Artemisia absinthium (wormwood) and Tripterygium wilfordii were superior to placebo in inducing remission, and preventing clinical recurrence of post-operative CD respectively.

CONCLUSIONS

Randomised controlled trials of herbal therapy for the treatment of IBD show encouraging results but studies remain limited and heterogenous. Larger controlled studies with stricter endpoints and better-defined patient groups are required to obtain more conclusive results on the use of CAM therapies in IBD.