This original article was published on January 15, 2014 at ndnr.com. It is the second part of our new series of posts on IBS, IBD, and SIBO that are very relevant in 2019.
In this second part of the comprehensive article on IBD Dr. Weiner explains the remaining 3 obstacles to cure. He also explains naturopathic foundational and effective treatments for Inflammatory Bowel Diseases (IBD) offering a deeper understanding of this condition.
Look forward to additional articles in this series on The IBS within the IBD, Use of Elemental Diets in IBS and IBD, and additional videos and summary articles including posts related to Chinese Medicine and Acupuncture as effective treatments for managing symptoms of IBS, IBD, and SIBO.
Read the full text of the original article here:
Gary Weiner, ND, LAc
Missed Part 1? Click to read Part 1 of this article.
OBSTACLE 5: SUB-OPTIMAL DIGESTION
We pay attention to the entire GI tract, which means addressing possible functional hypochlorhydria, pancreatic insufficiency (PI), bile acid insufficiency, and also bile acid malabsorption, which is a common feature of CD.29 PI is often associated with IBD with frequent bowel movements. There is little data to support HCL supplementation in IBD; however, we have seen profound improvement using this and even have one case where HCL supplementation has been responsible for sustained symptom remission. It is helpful to use laboratory testing to assess functional digestion and absorption problems, and then treat accordingly with tolerated agents and strategies.
OBSTACLE 6: STRESSORS AND PSYCHO-EMOTIONAL ISSUES
Stress appears to be a trigger and perhaps an antecedent of IBD, though data on interventions are poorly documented.30 The possible mechanisms by which stress could be translated into IBD symptoms include changes in motor, sensory and secretory gastrointestinal function, increased intestinal permeability, and changes in the immune system.31 Likewise, the relationships between the hypothalamic-pituitary-adrenal (HPA) axis activity, hypocorticism, and glucocorticoid receptor dysfunction have been tied to inflammatory and autoimmune diseases.32 Depression and anxiety are prevalent in patients with IBD and may influence disease expression.31 One study showed that a significant number of IBD patients felt that antidepressant treatment positively influenced their IBD.33
In our clinic we integrate classical acupuncture, homeopathy, counseling, and neural therapy, either through treatment in the clinic, or referral. If anxiety and depression are present, remedies (natural or pharmacologic) must be incorporated into the plan. We teach mindfulness-based stress reduction (MBSR) in our clinic in 8-week cycles, as outlined by Jon Kabat-Zinn.34 MBSR has been shown in several studies to impact inflammation in a variety of health conditions,35,36 and has been shown in one study to decrease C-reactive protein (CRP).37 Psycho-emotional imbalance and stress must be addressed in treatment for successful outcomes.
OBSTACLE 7: ADRENAL HYPOFUNCTION
One obstacle in managing some IBD cases is functional adrenocortical insufficiency, as described at length in the text, The Safe Uses of Cortisol, by Jeffries.38 It is surprising how little data exists on this phenomenon despite widespread agreement that the HPA axis is relevant to the mechanism of IBD.39 We screen IBD patients to find significant numbers with low salivary cortisols, 24-hour urinary cortisols, and, in some cases, morning serum cortisols. When adrenal salivary testing reveals a low cortisol concentration, low DHEA-S, and low 17-OH-progesterone, we maintain a high confidence level that low-dose hydrocortisone may contribute to symptomatic, if not endoscopic, remission. One fatigue study published in The Lancetindicated that low-dose hydrocortisone (10 mg or less) is not suppressive of adrenal function.40 Some cases respond well to dessicated adrenal extract and various adrenal supplements, but we have had more success with low-dose hydrocortisone, given according to bioidentical hormone replacement principles, than any other oral therapy.
OBSTACLE 8: CONSTITUTIONAL IMBALANCE
We do not have data supporting treatment of the “constitutions” of our patients, and this is the least evidence-based area in naturopathic medicine. When we refer to treatment of the “constitution,” we are referring to a dominant pattern of symptoms that lead us to prescriptions of homeopathic remedies, Chinese medicine treatments, and other interventions that we have learned about and frequently implement with success. We find it important to examine constitutional imbalances and address them as they present themselves, whether employing the simillimum using classical prescribing, or treating the indicated miasm or “reactional mode” using poly-pharmacy techniques. In our clinic, most patients receive acupuncture once a Chinese differential diagnosis has been established. A significant number of our IBD patients are intolerant of Chinese herbal formulas, except when they are well along the path to remission.
At Pearl we treat IBD in the following manner:
MANAGE THE ACUTE COMPETENTLY
Before going for the “root” of the condition, it is necessary to get acute symptoms under control. A shopping bag of hard-to-digest supplements will rarely do the job, so we rely on acupuncture, a well-chosen homeopathic remedy, the introductory phase of SCD, and, when necessary, oral corticosteroids to “manage” acute symptoms. Of course, there are other methods to consider, such as an “elemental diet,”41which has shown to be as effective as corticosteroids. We advise new doctors to refer for management of a flare if they are not confident and to request that the patient return when the flare is under control, and we recommend learning steroid protocols “cold,” to hold in reserve for when needed. We often compound a “friendlier” version of prednisone without binders and excipients through compounding pharmacies. We find that if we mismanage acute treatment, we may lose an IBD patient and miss the chance to work on the root of the condition.
PROVIDE NECESSARY SUPPORT
IBD patients typically arrive in our clinic after exhausting other avenues of care. They often present, expressing confusion about the choices they face, experiencing a conflict of paradigms, ie, between conventional treatments offering less-than-promising results and with dangerous side effects, and alternative and complementary care that is driven by a different set of principles and using treatments that appear to lack “proven results.” Patients may have been discouraged by medical professionals to engage in naturopathic therapies, or been told that “diet doesn’t matter.” What we ask of the patient – ie, to embrace a new paradigm—is immense. And when patients are flaring, they do not have a lot of energy to invest in their wellness and embrace complicated treatment. In our clinic, we compensate for this with a staff member, an occupational therapist who specializes in helping IBD patients to implement the necessary lifestyle changes to assure a successful treatment plan. We have set up systems, personnel, and a reimbursement strategy to provide programmatic assistance to help patients get well. The waxing and waning of IBD requires frequent follow-up, careful monitoring, and availability to address flares.
MONITOR RESPONSES CAREFULLY
As physicians, we believe it is important to share the concerns of gastroenterologists, not only to monitor signs and symptoms, but to assure mucosal healing and prevention of colorectal cancer, which occurs in a significant number of IBD patients.42 Regular surveillance appears necessary,43 with colonoscopy considered the gold standard for diagnosing early dysplastic alterations. It is also important to use biomarkers to assess clinical progress.44 Fecal biomarkers such as calprotectin and lactoferrin, as well as serological markers such as ESR and CRP, are valuable to gather at baseline and to monitor over time as a dietary strategy is implemented and obstacles to remission are removed.45,46 These markers are invaluable in helping to assess degrees of mucosal healing prior to further endoscopy, although mucosal healing has been defined as “complete absence of all inflammatory and ulcerative lesions in all segments of gut” at endoscopy.47
Finally, INTEGRATE, DON’T SEPARATE
IBD is one of those conditions where the troubling symptoms, profound discomfort of our patients, and the serious health risks of disease progression test our philosophical resolve. We employ sound naturopathic measures, and yet sometimes we cannot get the symptoms under control and stimulate mucosal healing. This is no time for philosophical grandstanding about what is natural; we need to be integrative and remember that we are physicians “specializing” in natural therapeutics but trained (and in many locales, licensed) to use pharmacologic agents appropriately. This is a disease in which management requires integration of our naturopathic skills with some of the modalities of our allopathic brothers and sisters.
IBD is where the rubber meets the road. The contact point of the tire (our medicine) with the road (the patient’s experience of the disease) should yield positive results. However, when we do not see adequate progress, the symptomatic and pathological pushback is so great that there had better be tread on those naturopathic tires.
The needed tread is integration, not separation. As we proceed with our pursuit of the condition’s root, we apply multiple therapies, observe the outcomes, adjust therapies as we go, and maintain awareness of our patient’s responses. We assume the responsibility to manage the case, or work with gastroenterologists or other providers to add medications when the condition flares, or remove medications when we begin to see signs that the vis medicatrix naturae will take the patient, as it often does, to the promised land.
Author, Gary Weiner, ND, LAc practices at Pearl Natural Health in Portland, Oregon, where he has developed an alternative and complementary care program for inflammatory bowel disease. He graduated from NUNM in 1997 and completed a 1-year residency in family medicine. He has served as adjunct faculty and clinical supervisor at NUNM, and is on the medical advisory board of the Northwest Crohn’s and Colitis Foundation of America. He is a recognized expert and speaker in the field of IBD, IBS and SIBO and the use of the Elemental Diet in the treatment of SIBO. He presents continuing education for naturopathic physicians. He works closely with gastro-enterologists and has presented to MDs in complementary care for IBD to 50+ gastroenterologists at the Oregon Gut Club, accredited by Providence Portland Medical Center. Dr Weiner lives with his wife and daughter in Portland, Oregon.
full reference list available at the original source