Adjunctive Care for Crohn’s Disease

I don’t often write about my private life because I like to keep my work and my family separate but I’m going to break my own rules and tell you a bit of a personal story today.

My husband has Crohn’s disease.

When we first met, he had just recently been diagnosed after months and months of debilitating digestive symptoms and extreme weight loss. I immediately wanted to know everything there was to know about Crohn’s disease and inflammatory bowel disease (IBD). Initially, this need to know was driven by an eagerness to help him and set him on the right path towards remission. However, over time, it became more of a fascination and a respect for an autoimmune disease that we really don’t know much about (but are learning more about every day!)

What I’ve learned over the years is that there isn’t a miracle treatment for this disease. One treatment that may induce remission in one person may not do anything for someone else. I’ve also learned that there are so many supportive therapies in Naturopathic Medicine that complement the therapies provided by gastroenterologists and that can sometimes be used as sole treatments in milder cases.

Before I get into the nuances of what these treatments are, let’s review what exactly Crohn’s disease is. Crohn’s disease is one of the two types of inflammatory bowel disease, the other being ulcerative colitis. Crohn’s disease is able to affect any part of the gastrointestinal tract from the mouth to the anus. However, the most commonly affected areas are the last part of the small intestine called the ileum or the first part of the colon. What results is chronic inflammation that can result in scar tissue formation and strictures in the intestines.

Causes and risk factors

We aren’t entirely certain what causes Crohn’s disease but we do know that genetics likely play a role as up to 20% of people with this condition have a close relative with Crohn’s as well. But what about the other 80%? Environmental factors are thought to contribute to the development of the disease as living in an urban area increases the risk of developing Crohn’s in comparison to living in a rural area.

We also know that the types of gut flora are different in people with Crohn’s disease than those without. Although everyone has bacteria and fungi that live in their gut, the amounts can differ from person to person. People with Crohn’s disease have been found to have significantly higher levels of two types of bacteria called Escherichia coli and Serratia marcescens as well as one fungus called Candida tropicalis¹. Interestingly, mouse models of Crohn’s disease has also linked Candida tropicalis to Crohn’s disease.

These three microorganisms are able to form a biofilm together, a colony of microorganisms that adheres to the gut wall. It is thought that this biofilm could trigger the inflammatory process in Crohn’s disease.

Diagnosis of Crohn’s Disease

If your doctor is investigating for possible inflammatory bowel disease, you will likely receive a colonoscopy or endoscopy to look for inflammation.

As I am unable to refer out for a colonoscopy, I usually start my own investigations with a fecal test called fecal calprotectin. This test is able to detect inflammation in the small intestine and will differentiate irritable bowel disease (IBS) from IBD with up to a 95% sensitivity and 91% specificity².

Treatment of Crohn’s Disease

If you have been diagnosed with Crohn’s disease, you have likely already started some sort of treatment plan with your gastroenterologist whether that is using 5-aminosalicylic acid (e.g. Pentasa, Asacol), immunosuppressants (e.g. azathioprine) or a biological drug (e.g. infliximab [Remicade, Inflectra], adalimumab [Humira]).

If you are wondering what else you can do, you are in the right spot. It turns out there are a lot of wonderful supportive therapies I can offer my patients and I will let you in on my secrets in this next section.

Naturopathic Adjunctive Care

The Specific Carbohydrate Diet (SCD)

The SCD was originally created by Sidney Haas in 1924 to help manage celiac disease. In 1951, he published a medical textbook that described using the SCD not only for celiac disease but also for the treatment of inflammatory bowel disease.

Since that time, there has been numerous studies supporting the use of the SCD in the treatment of both Crohn’s disease and ulcerative colitis. In fact, the Inflammatory Bowel Disease Center at Seattle Children’s Hospital uses the SCD as one of their treatment options for children with IBD³! This diet not only improves the symptoms of IBD but also the laboratory parameters^3,4,5,6,7.

It is thought that the Specific Carbohydrate Diet works by altering the intestinal flora which, as I discussed above, is believed to play a role in the development of Crohn’s disease.

Antimicrobials

Modifying the gut flora through the use of antimicrobial agents and probiotics is another potential treatment for IBD in order to colonize the gut with more anti-inflammatory strains of bacteria. I will occasionally run a comprehensive stool analysis in my Crohn’s patients to culture what types of bacteria and fungi are present in the bowel, both healthy as well as pathogenic strains, in order to give me targets for antimicrobial therapy whether that is through antibiotics, antifungals, or herbs.

We also know that Small Intestine Bacterial Overgrowth (SIBO) is much more prevalent in those with Crohn’s disease than in the regular population (more than a 9-fold increased risk!)⁸. SIBO is characterized by elevated levels of bacterial in the small intestine and will significantly raise fecal calprotectin levels in those with Crohn’s indicating that it increases the degree of inflammation in the intestine. Treating SIBO (one of my other favourite things to treat) in affected individuals has the potential to lower the degree of inflammation, modify the gut flora, and improve the absorption of nutrients.

Low Dose Naltrexone (LDN)

LDN is slowly gaining recognition as a safe treatment for a variety of autoimmune diseases. It works by tricking the body into creating endorphins which have a modulating effect on the immune system. This medication can be taken by both children and adults, and has no serious side effects that we are aware of.

In one study on pediatric patients, after 8 weeks on LDN, 25% of the children were in remission and another 67% had improved with only mild disease severity⁹. This means that 92% of the participants were either in remission or only had mild disease after only 8 weeks on LDN! Another study on adults with Crohn’s disease showed that 89% of patients exhibited a positive response to LDN and 67% achieved remission¹⁰!

LDN has become one of my go-to treatments with Crohn’s disease due to the safety profile and the success rates. It can be combined safely with most other medications used in Crohn’s disease with the exception of opiates being prescribed for pain (e.g. morphine, Tylenol 3, etc.).

Vitamin D

Vitamin D is essential for so many different aspects of our health including our immune system. It has been found that up to 65% of patients with Crohn’s disease are vitamin D deficient. Interestingly the severity of the disease correlates negatively with vitamin D status^11,12,13, meaning that the more deficient you are, the worse the disease. Maintaining a healthy vitamin D status is always included as part of my treatment plan for Crohn’s disease.

If you have not had your vitamin D levels checked, I would caution against taking high doses of vitamin D as this nutrient has the potential to reach toxic levels quite easily. Your vitamin D levels can be checked easily through the blood and your naturopathic doctor will be able to recommend an appropriate dose of supplementation or vitamin D injections to bring your vitamin D back to a healthy level.

IV Therapy

If you are in the midst of a Crohn’s flare with severe diarrhea, my patients have often noted benefit to IV nutrient therapy to replenish their body until they get the flare under control. IV nutritional therapy is able to provide high doses of vitamin C, magnesium, calcium, B vitamins, and minerals, with the benefit of bypassing the digestive tract so that you get the maximal benefit of all the nutrients that are given.

If you would like to book an appointment to either look into whether you have IBD, or would like some support with adjunctive therapies, you can do so at the link provided.

Best of luck!

References

1. Hoarau, G., Mukherjee, P. K., Gower-Rousseau, C., Hager, C., Chandra, J., Retuerto, M. A., … Ghannoum, M. A. (2016). Bacteriome and Mycobiome Interactions Underscore Microbial Dysbiosis in Familial Crohn’s Disease. MBio, 7(5).
2. Roon, A. C. V., Karamountzos, L., Purkayastha, S., Reese, G. E., Darzi, A. W., Teare, J. P., … Tekkis, P. P. (2007). Diagnostic Precision of Fecal Calprotectin for Inflammatory Bowel Disease and Colorectal Malignancy. The American Journal of Gastroenterology, 102(4), 803–813.
3. Obih, C., Wahbeh, G., Lee, D., Braly, K., Giefer, M., Shaffer, M. L., … Suskind, D. L. (2016). Specific carbohydrate diet for pediatric inflammatory bowel disease in clinical practice within an academic IBD center. Nutrition, 32(4), 418–425.
4. Burgis, J. C. (2016). Response to strict and liberalized specific carbohydrate diet in pediatric Crohn’s disease. World Journal of Gastroenterology, 22(6), 2111.
5. Cohen, S. A., Gold, B. D., Oliva, S., Lewis, J., Stallworth, A., Koch, B., … Mason, D. (2014). Clinical and Mucosal Improvement With Specific Carbohydrate Diet in Pediatric Crohn Disease. Journal of Pediatric Gastroenterology and Nutrition, 59(4), 516–521.
6. Suskind, D. L., Wahbeh, G., Gregory, N., Vendettuoli, H., & Christie, D. (2014). Nutritional Therapy in Pediatric Crohn Disease. Journal of Pediatric Gastroenterology and Nutrition, 58(1), 87–91.
7. Suskind, D. L., Wahbeh, G., Cohen, S. A., Damman, C. J., Klein, J., Braly, K., … Lee, D. (2016). Patients Perceive Clinical Benefit with the Specific Carbohydrate Diet for Inflammatory Bowel Disease. Digestive Diseases and Sciences, 61(11), 3255–3260.
8. Ricci, J. E., Chebli, L. A., Ribeiro, T. C., Castro, A. C., Gaburri, P. D., Pace, F. H., … Chebli, J. M. (2017). Small-Intestinal Bacterial Overgrowth is Associated With Concurrent Intestinal Inflammation But Not With Systemic Inflammation in Crohn’s Disease Patients. Journal of Clinical Gastroenterology, 1.
9. Smith, J. P., Field, D., Bingaman, S. I., Evans, R., & Mauger, D. T. (2013). Safety and Tolerability of Low-dose Naltrexone Therapy in Children With Moderate to Severe Crohn’s Disease. Journal of Clinical Gastroenterology, 47(4), 339–345.
10. Lichtenstein, G. (2008). Low-Dose Naltrexone Therapy Improves Active Crohns Disease. Yearbook of Gastroenterology, 2008, 136–137.
11. Li, X.-X., Liu, Y., Luo, J., Huang, Z.-D., Zhang, C., & Fu, Y. (2019). Vitamin D deficiency associated with Crohn’s disease and ulcerative colitis: a meta-analysis of 55 observational studies. Journal of Translational Medicine, 17(1).
12. Ham, M., Longhi, M. S., Lahiff, C., Cheifetz, A., Robson, S., & Moss, A. C. (2014). Vitamin D Levels in Adults with Crohnʼs Disease Are Responsive to Disease Activity and Treatment. Inflammatory Bowel Diseases, 20(5), 856–860.
13. Joseph, A.J., George, B., Pulimood, M.S., Chacko, A. (2009). 25 (OH) vitamin D level in Crohn’s disease: association with sun exposure & disease activity. Indian Journal of Medical Research, 13o(2), 133-137.