At the ECCO 2019 meeting, a topical review focused on the most commonly used complementary and psychotherapy interventions in inflammatory bowel disease (IBD). The two speakers, Dr Joana Torres (New University of Lisbon, Portugal) and Prof. Stephan Vavricka (Gastroenterology and Hepatology Center, Zurich, Switzerland), noted a lack of rigorously conducted trials in this field, which is why further research is needed before any solid recommendations can be made.
Prof. Vavricka said 20-60% of IBD patients use some form of complementary and alternative medicine (CAM) . A topical review was performed aiming to inform physicians and to provide some evidence to guide an informed discussion with their patients on CAM. There were three working groups:
- biologically based practices, such as herbs, cannabis, probiotics;
- manipulative and body-based interventions; and
- mind-body medicine and psychotherapeutic interventions.
Biologically based practices
Quite a few studies (even randomised trials) are available on the induction and maintenance of remission in both ulcerative colitis and Crohn’s disease. Although the use of cannabis may be associated with a reduction of some symptoms of IBD, there is no firm evidence to show that it positively alters the course of the disease. As a complementary therapy to 5-ASA, curcumin may be effective in inducing remission in mildly to moderately active ulcerative colitis. Curcumin, psyllium, and an herbal preparation consisting of myrrh, chamomile, and coffee charcoal may be effective as complementary therapy in ulcerative colitis.
Vitamin D may play an important role in the pathogenesis of IBD. Deficiency of vitamin D often occurs in IBD patients. Prof. Vavricka: “There is insufficient evidence, however, to support the use of any vitamins or minerals to induce or maintain remission in ulcerative colitis or Crohn’s disease.”
Dietary fibre supplements, such as prebiotics (fructo-oligosaccharides) and short-chain fatty acids, psyllium, and germinated barley, may stimulate the growth of selected beneficial microbial species (i.e. Bifidobacteria, Faecalibacterium prausnitzli). There is insufficient evidence to support the use of dietary supplements or specific diets to induce or maintain remission in Crohn’s disease or ulcerative colitis. However, future research should focus on diet as a complementary therapy.
Fish oil is known to reduce the production of certain pro-inflammatory markers, such as IL-1, IL-6 and TNF. Omega-3 fatty acids have shown a marginal benefit vs placebo in maintaining remission in Crohn’s disease. However, study quality and heterogeneity of trials limit the value of these findings.
Some studies have suggested that acupuncture could improve inflammation, symptoms, and quality of life, but these studies mostly lack sufficient quality. According to Dr Torres the same may be said of moxibustion, i.e. the burning dried mugwort (muxa) directly or indirectly on acupoints to generate warmth stimulation. “Therefore, we conclude there is insufficient evidence to support the use of acupuncture or moxibustion, either as monotherapy or in combination, for the treatment of active ulcerative colitis or Crohn’s disease.”
Further, exercise may protect from IBD. A prospective study from the Nurses' Health Study (NHS) cohorts found that the risk of Crohn’s disease among women in the highest quintile of physical activity was 0.64 compared with women in the lowest quintile . Active women with at least 27 metabolic equivalent task hours per week of physical activity had a 44% lower risk of Crohn’s disease compared with sedentary women with <3 metabolic equivalent of task-hours per week. Physical activity was not associated with risk of ulcerative colitis (P for trend 0.46). Several studies have shown the safety of mild-to-moderate exercise programmes in IBD. No detrimental effects on disease activity were found. Exercise programs are associated with a higher quality of life. Overall, exercise can have beneficial effects on overall health, physical wellbeing, perceived stress, and quality of life of IBD patients. There is promising, albeit limited, evidence of the role of exercise both in protecting from IBD and in disease management.
Psychotherapy and mind-body interventions
Dr Torres stressed that there are high rates of functional gastro-intestinal disorders, anxiety, and depression, especially in patients with active disease. Also, some evidence suggests that stress is associated with a higher relapse risk. Cognitive behavioural therapy has shown no effect on disease activity, but positive effects on quality of life have been reported. Outcomes on anxiety and depressions are mixed. Results of two randomised controlled trials of yoga indicate no effect on inflammatory markers but improvements in quality of life, anxiety and abdominal pain. Meditation and relaxation may improve quality of life and possibly decrease inflammatory activity in IBD. Evidence of the effect of mindfulness-based interventions on disease activity are limited. Gut-directed hypnotherapy is efficacious in functional gastro-intestinal disorders, but evidence of any effect on IBD is limited.
Keywords: Crohn’s disease, ulcerative colitis, vitamin D, diet
- Torres J and Vavricka S. ECCO 2019.
- Khalili H, et al. BMJ. 2013 Nov 14;347:f6633. doi:10.1136/bmj.f6633.
The content and interpretation of these conference highlights are the views and comments of the speakers/authors.