‘Opening the discussion’: Complementary therapy in IBD
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Jami Kinnucan, MD, assistant professor at the University of Michigan, spoke with Healio about cannabis use among patients with ulcerative colitis and Crohn’s disease, the impact of diet on IBD management and the overall role of complementary therapy in the GI field, specifically for patients with IBD.
How important are complementary or alternative therapies for symptom management and quality of life for patients with IBD?
One of the biggest unmet needs in current IBD care is the lack of understanding of complementary and alternative therapies. I refer to them as complementary therapies because the data, which unfortunately are limited, really inform us on how we can complement our current medical therapies. The most commonly used among IBD patients include dietary modifications, supplements, yoga, probiotics and cannabis. How do we supplement our current therapies to optimize them further with these other methods? The word alternative actually means substitution. What we try to avoid with patients is using complementary therapies as a substitution for better studied medical therapies with both proven effectiveness and safety in managing IBD and preventing IBD-related complications. However, we know that many patients do not discuss complementary therapies with their providers, it’s important for providers to ask patients about what other therapies they are using to control IBD-related symptoms.
In fact, on our intake forms we ask patients about complementary therapies that they might be using, including some of the ones I listed, because we realize that providers don’t often discuss complementary therapies with their patients, or patients feel uncomfortable discussing with their health care provider. Several reasons have been revealed in survey based studies.
One is lack of provider understanding or patient fear of provider disapproval. The truth is, many providers do not have the knowledge, but would like to understand more. So, we as a community are trying to professionally educate our colleagues about what complementary therapies are and what the data show and don’t show as a first step. For example, at the Crohn’s and Colitis Congress in Austin, Texas in January 2020 there was an excellent talk given by the National Center for Complementary and Integrative Health (NCCIH) director Dr. Helene Langevin on complementary therapies in IBD. It is important that we initiate the discussion so we can understand how patients are using complementary therapies to improve their quality of life with IBD
If a patient is using cannabis to treat ongoing abdominal pain and it has been effective, but we don’t ask about this therapy or these ongoing symptoms we might miss that this patient actually has ongoing inflammation related to Crohn’s disease. By having that discussion, we can really gain insight to how patients are doing and how they are managing their disease on their own in addition to the medicines we are prescribing.
What does recent research suggest about the use of medical cannabis among patients with IBD?
There are several large survey based studies in the US and Canada showing that patients are using cannabis to treat IBD symptoms. More recent studies have shown that more patients have used or are currently using cannabis to treat IBD-related symptoms. These studies have also shown that patients feel better when they use cannabis. However, these studies are limited in number and number of patients included; less than 200 patients have been studied in randomized controlled trials in Crohn’s disease and ulcerative colitis.
The symptoms that were improved with cannabis use included abdominal pain, nausea, vomiting and diarrhea, and appetite. Some secondary benefits reported were improved sleep and reduced symptoms of anxiety and depression. But what the studies have failed to show is improvement in disease activity. Looking at markers of disease activity – C-reactive protein and hemoglobin and fecal calprotectin – the studies have not seen a significant difference between cannabis use and non-cannabis. The concern with cannabis use in IBD is that many patients discontinue their conventional medical therapy. The presumption is that their traditional medical therapy is not working given ongoing symptoms, which suggests persistent symptoms might actually be due to non-inflammatory causes or need for optimization of conventional medical therapy. We know that discontinuation of medical therapy can worsen outcomes associated with IBD. It’s important that we educate health care providers about use so that we can better educate our patients about the effects of cannabis in IBD.
What challenges come with cannabis and CBD pain management in the GI field in general, and for IBD patients specifically?
As discussed, the most important thing to consider is that cannabis use is underrecognized: providers don’t ask about it and patients don’t talk about it, unless they are directly asked.
As providers, the first step is just opening the door for discussion with our patients. This gives us an opportunity to improve our understanding on daily symptoms impacting quality of life and the treatments that our patients are using to control these symptoms and improve their quality of life. Once the conversation has been started, the opportunity to educate our patients about what we know and what we don’t know about cannabis in IBD. While we know it helps control symptoms, there are no convincing data that cannabis improves disease activity. So, while our patient’s pain is improved, the disease process is still present, and it is important for them to continue their current medical therapy.
The other challenge once we know our patients are using cannabis to manage IBD symptoms, is that we have little to no guidance on formation, route or dosage of cannabis that might be effective. The studies have looked at various formulations (CBD:THC ratios), route (inhalation vs. oral) and dosage so it is difficult to make conclusions. The studies that used a combination ratio of CBD:THC had greater impact on symptoms that those that used CBD formulations alone. However, our patients often ask for guidance. “What formulation should I use? What frequency? Which route is best?” Inhalation route has the potential for more risk, but is faster onset, more accessible for patients and significantly cheaper. On the other hand, oral administration is slower onset but has longer duration of effect, benefit given lack of inhalation, however it can be less accessible and more cost prohibitive. Many providers do not have an intimate understanding of the details of cannabis and dosing. So if a patient is using cannabis or a provider feels a patient might benefit from cannabis adjuvant therapy, we have limited guidance on what to tell patients surrounding dosing/frequency at this point. Much of this limitation is driven by the lack of large randomized controlled trials due to current federal limitations on cannabis.
What does research suggest about the best type of diet and IBD?
Diet and IBD is one of the top questions that patients have during their IBD visit. “What did I eat to cause my disease? What can I eliminate from my diet to treat the inflammation? Is there a recommended diet that can replace my medications?” Our best resource is the partnership we have with our dietitians. Each patient that comes through our IBD clinic often works with one of our dietitians to dive into the details of these questions. Additionally, I provide patients with an excellent resource that we have put together for the Crohn’s and Colitis Foundation with patient friendly education .
We are learning more and more about the impacts of diet on IBD activity and microbiome. We know there is a relationship, we are working toward getting the answers we need to better guide patients. My overall advice to patients is to eat a well-balanced diet low in processed meats and sugars, high in health fats and lean proteins, high in fiber; this is basically the Mediterranean diet. Providers often misguide patients to avoid fiber; it is important that we partner with our patients and dietitians to individualize diet approach in each patient. If patients are interested in helping further our understanding, they should look at various diet studies in IBD including the DINE-CD study through the Crohn’s and Colitis Foundation looking at a specific carbohydrate compared with the Mediterranean diet regarding managing disease activity in Crohn’s disease patients.
The take home, majority of patients modify their diet especially when they have active disease, however many do not go back to a more liberalized diet often avoiding fiber and other nutritious foods. They are at risk for malnutrition due to the disease and dietary modifications. Partner with a good dietitian to help you better manage these patients and improve their quality of life with food. Be cautious of the “fad” diets that are advertised to “cure” IBD. We know that patients can feel better when they modify their diet, but we are still gaining understanding on the impact that dietary modifications can have as adjuvant therapy to treat inflammation.
5 years from now, 10 years from now, where are complementary therapies in our ideal treatment algorithm?
We can start this now. All providers seeing IBD patients should be asking their patients about other therapies/practices that they are using to manage their IBD. This should be part of a standard new patient intake form in addition to return visit evaluation, as patients’ practices change over time. Asking directed questions might be of most benefit as some patients don’t consider some of the things they do (ie, yoga to manage ongoing joint pain) as complementary therapy. I think complementary therapies remain an underrecognized treatment in IBD and often underused due to lack of provider awareness.
We need more studies, especially in cannabis, looking at the impact of these therapies on disease outcomes. This will help us better inform our patients. Further, these studies can help guide us on possible risks associated with using complementary therapies. Remember that supplements and cannabis are not FDA approved and remain unregulated. We want to be able to offer guidance but not harm to our patients. Nothing is risk free, even if it seems “natural”. At the end of the day, patients and providers need to participate in shared decision-making to decide what is the best treatment approach for their IBD, maximizing benefit and improved disease outcomes and quality of life and minimizing risk.
We need to have that open discussion with patients first so that we can address how complementary therapies can fit that unmet need.
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