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Arthritis Case Study Colonoscopy Crohn's Disease DIAGNOSIS DIAGNOSTIC TESTING Digestive EAT Enemas Inflammation Leaky Gut Nutrition Pharmaceuticals RESEARCH Stomach Ache STORIES-OF-HOPE SYMPTOMS TREATMENT Ulcerative Colitis

Case Study: Camel Milk allows full stop of Entocort steroid and not needing Humira

A case study published in the American Journal of Gastroenterology showed that a 22-year-old patient with moderate to severe Crohn’s Disease showed significant improvement from this milk.

For this article, I’ll call this man John.

His Crohn’s Disease Activity Index(CDAI) score of 400.

According to the Merck Manual, his CDAI reveals mild to moderately active Crohns’ Disease

0 to 149 points:  Asymptomatic remission
150 to 220 points: Mildly to moderately active Crohn’s disease
221 to 450 points: Moderately to severely active Crohn’s disease
451 to 1100 points: Severely active to fulminant disease

John had watery diarrhea and left-sided abdominal pain. His stool cultures were negative, blood was seen in his stool and he was given both Flagyl® and Cipro® in the ER.

A CT scan of the abdomen/pelvis revealed diffused long segment thickening of the terminal ileum and mild thickening of the cecum.

A colonoscopy revealed moderate to severe pancolitis, ulcerations, and cobblestoning of the terminal ileum. Biopsies revealed chronic active colitis, crypt abscesses, and chronic active ileitis.

John started the steroid Entocort(budesonide) at 9mg daily and he saw improvement. According to drugs.com Entocort EC oral delayed-release capsules 3mg  cost $2412.28 for quantity 100. 

Humira (adalimumab)‎ was suggested however John and his family chose an alternative therapy. According to drugs.com a Humira subcutaneous kit costs $5810.97 for  a 2ea kit. AbbVie, the manufacture of Humira states that you may receive vaccines, except for live vaccines while using HUMIRA and that children should be brought up to date with all vaccines before starting HUMIRA

Humira is a a tumor necrosis factor (TNF) blocker indicated for treatment of Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), Psoriatic Arthritis (PsA), Ankylosing Spondylitis (AS), Adult Crohn’s Disease (CD), Pediatric Crohn’s Disease, Ulcerative Colitis (UC), Plaque Psoriasis (Ps), Hidradenitis Suppurativa (HS) and Uveitis (UV).

AbbVie’s recommend dosage ranges from weekly or every other week.  Based on the drugs.com pricing this would come out to $302,170 or $151,085 annually. Some may qualify for pharmacy card savings.

Instead of Humira, t
hey decided on a natural and more affordable option, namely  Camel Milk, just 8oz three times daily. If you’re in Europe,  use this link.

John’s symptoms reduced enough that he was able to stop Entocort just a week later. Except for right hip pain from Arthritis, his symptoms were completely lessened, according to the case report.

John had another colonoscopy a year later which showed much improvement, with less and shallower ulcerations in his terminal ileum.

Inflammation was now limited to just the cecum and pseudopolyp (scar tissue mass), in just the ascending colon.

He was entirely asymptomatic and even gained 11pounds, increasing from 139 to 150lb.

A multi-site study out of Egypt and Saudi Arabia showed that  Camel Milk (Europe: use this link.)  reduced colitis inflammation and oxidative stress in rats. Both the TNF-a and IL-10 cytokines were checked

To learn which inflammatory markers are high in your body, you can order lab tests from home here

Camel Milk has been known to promote glutathione production, deliver beneficial strains of Oligosaccharides, which contribute to digestive health by decreasing gut permeability and nourishing a healthy microbiome. They also serve as prebiotics. Because oligosaccharides also aid in cell recognition and cell binding, they play a vital role in immune function.

Camel Milk has three times more vitamin C than cow’s milk and 10 times higher in iron. With malabsorption and anemia often problems amongst those with gut dysbiosis, leaky gut, and often those with Crohn’s Disease and Ulcerative Colitis, this could be another reason why Camel Milk yielded such positive results to John.

Several studies on allergies (children who were allergic to dairy and just about everything else) showed significant improvement with camel’s milk They tolerated the milk, healed, and became less allergic and reactive in general.

Goat milk is often more tolerable than Cows milk for adults and children with Crohn’s and Colitis.  Studies have actually shown that Camel Milk is an even safer choice than Goat Milk.

Camel Milk has even been shown to inhibit mycotoxins, including Aspergillus. Mold and mycotoxins are often a  hidden root-cause of Inflammatory Bowel Disease and other auto-immune experiences.

My favorite Camel Milk (Europe: use this link.) company has been featured in the Los Angeles Times, Wall Street Journal, New York Times, and even Time Magazine.

Right now they are offering a risk-free trial. This means that you can return it if you do not like it.

 

Camel Milk also delivers Rare Proteins The most powerful immune active components are Lactoferrin, Immunoglobulins, Cytokines, and Lysozyme. These proteins are unique to camel milk and provide ultimate support to your brain, gut, and immune health. All these are antioxidants that can scavenge free radicals and reduce oxidative stress.


They have been verified by the non-GMO project, are Keto certified, EWG Verified, Gluten-Free, and Paleo Approved.
No Added Hormones, ✓Seasonally Grass-Fed, ✓Non-Homogenized

Camel milk (Europe: use this link.) contains a low-fat content of 2% and these fats are mostly omegas. The proteins are thought to contain a number of powerful bactericides, viricides, and fungicides. The immune proteins are 1/10 the size of human ones and are very potent. Some of the proteins are thought to repair tissue damage. The potential efficacy of camel milk in Crohn’s disease has not been studied although there are antidotal accounts for its effectiveness. It is, therefore concluded that camel milk has the potential of repairing damaged tissue. Further studies need to be done.

References

The inhibitory effect of camel’s urine on mycotoxins and fungal growth: African Journal of Agricultural Research: Amira Hassan Abdullah Al-Abdalall: Department of Botany and Microbiology, Faculty of Science for Girls, King Faisal University, El-Dammam, Kingdom of Saudi Arabia: 2010:
https://academicjournals.org/journal/AJAR/article-abstract/43879C334505

 

International Scholarly Research Notices: Camel Milk Is a Safer Choice than Goat Milk for Feeding Children with Cow Milk Allergy: Mohammad Ehlayel,  Abdulbari Bener, Khalid Abu Hazeima,  and Fatima Al-Mesaifri 

International Journal for Vitamin and Nutrition Research – Z. Farah, R.Rettenmaier, D. Atkins:  Vitamin Content of Camel Milk: 1991: 1 Laboratory of Dairy Science, Swiss Federal Institute of Technology Switzerland and Ol Maisor Farm Rumuruti Kenya:

International Journal of Research Studies in Biosciences (IJRSB): Camel Milk: A Boon to Mankind
Wajiha Gul, Najaf Farooq, Dania Anees, Uroosa Khan, Filza Rehan.
Faculty of Pharmacy, Jinnah University for Women, Karachi, Pakistan
https://www.arcjournals.org/pdfs/ijrsb/v3-i11/4.pdf

https://www.merckmanuals.com/medical-calculators/CDAI.htm

Predicting the Crohn’s disease activity index from the Harvey-Bradshaw Index
https://pubmed.ncbi.nlm.nih.gov/16633052/

Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study
https://pubmed.ncbi.nlm.nih.gov/1248701/

Camel Milk as an Alternative Treatment for Crohn’s Disease
Rosenheck, David MD; Ravee, Yaniv MS; Yagil, Reuven DVM
https://journals.lww.com/ajg/Fulltext/2012/10001/Camel_Milk_as_an_Alternative_Treatment_for_Crohn_s.1264.aspx

JFK Medical Center in Edison, NJ,  University of Medicine of New Jersey in Newark, NJ and Ben-Gurion University of The Negev, Beer Sheva, Israel.

Food and Chemical Toxicology: Camel’s milk ameliorates TNBS-induced colitis in rats via downregulation of inflammatory cytokines and oxidative stress
Hany H Arab, Samir Salamaa,  Ahmed H Eidde, Hany A Omard, El-Shaimaa A Arafad, Ibrahim A Maghrabi
Taif University, Saudi Arabia, Cairo University, Cairo Egypt, National Organization for Drug Control and Research (NODCAR), Dokki, Cairo, Egypt, Beni-Suef University, Beni-Suef
https://www.sciencedirect.com/science/article/abs/pii/S0278691514002142?via%3Dihub

Abbvie Humira Medicine Guide  https://www.rxabbvie.com/pdf/humira_medguide.pdf and https://www.rxabbvie.com/pdf/humira.pdf
Drugs.com: Humira: One Drug, Nine Uses, Billions of Dollars: https://www.drugs.com/slideshow/humira-one-drug-nine-uses-billions-of-dollars-1210

 

Categories
Asacol Corticosteroids Enemas Lialda-Mesalamine Pharmaceuticals Prednisone-Deltasone Rowasa Suppository TREATMENT

Pharmaceutical Options

  • Aminosalicylates (5-ASA) – Oral
    • Sulfasalazine [Azulfidine, Azulfidine EN-tabs]
    • Mesalamine [Lialda, Pentasa, Delzicol, Asacol HD] Olsalazine [Dipentum]
    • Balsalazide [Giazo, Colazal]
  • Aminosalicylates (5-ASA) – Rectal suppositories and enemas
    • Mesalamine [Canasa, Rowasa, sfRowasa]

  • Corticosteroids and Glucocorticoids
    • Prednisolone [Pred Forte, Omnipred, Pred Mild, , Orapred ODT, Millipred DP, Veripred 20, and Pediapred]
    • Prednisone [Deltasone, Rayos, Prednisone Intensol]
    • Budesonide [Entocort, Uceris, Pulmicort, Rhinocort Allergy, and Pulmicort Flexhaler]
    • Methylprednisolone [Solu-Medrol, Medrol, ReadySharp Methylprednisolone, P-Care D40, P-Care D80, and Depo-Medrol]

  • Immunosuppressive and Immunomodulators
    • Ustekinumab [Stelara]
    • Adalimumab [Humira, Humira Pen, Humira Pen Crohn’s-UC-HS Start, Humira Pediatric Crohn’s Start, Humira, and Humira Pen Psoriasis-Uveitis]
    • Azathioprine [Azasan, Imuran]
    • Infliximab [Remicade]
    • Cyclosporine [ Sandimmune, Restasis MultiDose, Neoral, Restasis, and Gengraf]
    • Tacrolimus [Envarsus XR, Astagraf XL, Protopic, and Prograf]
    • Golimumab [Simponi ARIA and Simponi]
    • Etanercept [Enbrel, Benepali]
  • Immunosuppressive And Chemotherapy
    • 6-mercaptopurine, 6-MP [Purinethol, Purixan]
    • Methotrexate[Otrexup (PF), Xatmep, Trexall]

      Pain Relievers

      Orexigenic
    • Dronabinol [Marinol]

      Analgesic
    • Acetaminophen [TYLENOL, Ofirmev, FeverAll, Tylophen, Pharbetol, Infant’s Pain Relief, Mapap, Tactinal Extra Strength, PediaCare Fever Reducer, Non-Aspirin Extra Strength]

      Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)I
    • Ibuprofen [Advil, NeoProfen, Caldolor, Ibuprofen IB, Advil Liqui-Gel, Infant’s Motrin, Infant’s Ibuprofen, Infant’s Advil, Children’s Profen IB, Ibu-Drops]
    • Ketorolac [Toradol, Acuvail, Acular LS, Acular, and ReadySharp ketorolac]

      I recommend trying to stay away from NSAIDs as I’ve personally gone from normal bowel movements to bleeding ulcers just from taking NSAIDs. During one hgospitlziation one medical doctgor hospitalzie conmvicend me, in my vulnerble state, that Toradol has  different MOA(Mechanism Of Action and would not cause any problems. Since I was in a high level of pain, and not thinking clearly,  I agreed. Thankfully the GI and ID team overulled that decision a few days later to save me from further complications. 


      GABA Analogue
    • Gabapentin [Gralise, Neuraptine, Gralise 30-Day Starter Pack, SmartRx Gaba-V Kit, Horizant, and Neurontin]

      Anesthetic
    • Ketamine [Ketalar, Ketanest, and Ketaset]

      Opioids / Narcotics
    • Codeine (only available in generic form)
    • Fentanyl (Actiq, Duragesic, Fentora)
    • Hydrocodone (Hysingla ER, Zohydro ER)
    • Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
    • Hydromorphone (Dilaudid, Exalgo)
    • Meperidine (Demerol)
    • Methadone (Dolophine, Methadose)
    • Morphine (Astramorph, Avinza, Kadian, MS Contin, Ora-Morph SR)
    • Oxycodone (OxyContin, Oxecta, Roxicodone)
    • Oxycodone and acetaminophen (Percocet, Endocet, Roxicet)
    • Oxycodone and naloxone (Targiniq ER)
  • Janus Kinase (JAK) Inhibitor 
    •  Tofacitinib [Xeljanz, Jakvinus]

  • Biologic/Biosimilar Therapies
    • Adalimumab [Humira Pen, Humira Pen Crohn’s-UC-HS Start, Humira Pediatric Crohn’s Start, Humira, and Humira Pen Psoriasis-Uveitis]
    • Golimumab [Simponi ARIA and Simponi]
    • Infliximab [Remicade]
    • Vedolizumab [Entyvio]
    • Infliximab-abda
    • Infliximab-dyyb
    • Infliximab-qbtx

  • Antibiotics:
    • Metronidazole [Flagyl]
    • Ciprofloxacin [Cipro, Proquin]
    • Rifaximin [Xifaxan]
    • Ampicillin
    • Tetracycline
    • Augmentin [ AugmentinXR, Augmentin ES-600, and Augmentin]

  • Calceineurin inhibitor
    • Tacrolimus [Envarsus XR, Astagraf XL, Protopic, and Prograf]
Categories
Crohn's Disease Digestive Enemas Pharmaceuticals Supplements Suppository Ulcerative Colitis

Therapeutic Retention Enemas: An Underutilized Modality for Ulcerative Colitis

The use of therapeutic enemas has a robust tradition in the history of naturopathic medicine. In addition, my own grandfather, a medical doctor, had a habit of administering a cleansing enema to any of his 8 children who displayed any sign of acute illness, which, in the words of my brother, “if nothing else, probably cut down on malingering.” Despite these facts, I made it into my 30s and through my entire professional training as a naturopathic doctor without having given, received, or even witnessed an enema of any type.

This article focuses on the use of enemas in ulcerative colitis (UC) – an autoimmune inflammatory bowel disease (IBD). Two-thirds of UC patients have distal disease, confined to the left side of the colon. Therapeutic retention enemas are highly indicated for this population, but may also be utilized for patients with more extensive disease, up to and including pancolitis.

Rectally-administered therapies are underutilized in IBD, due in part to physician perception of patient unwillingness to use them, and embarrassment in discussing rectal modalities1; however, in my practice I’ve prescribed and administered hundreds of enemas and found them to be extremely helpful in the treatment of UC, especially left-sided UC and ulcerative proctitis, the latter of which is notoriously stubborn to medical management.

ENEMAS, IN GENERAL

An enema, meaning “to send in,” is also known as a clyster, meaning “to wash out.” These 2 etymologies reflect the 2 basic types of enemas: retention enemas are used to deliver a medicinal substance to the colorectum for topical action or absorption via the mucosa, while cleansing enemas are used to wash out the contents of the colon.

Retention enemas are the topic of this article. They can be delivered in a small volume, for example half-ounce (15 mL) vitamin E or colostrum enemas, 60 mL mesalamine enemas, or 100 mL butyrate enemas, or in even larger volumes, such as 500+ mL calendula tea enemas. Retention enemas are generally considered safe for patients with IBD; however, incorrect insertion method has on rare occasion been associated with rectal perforation.2

Cleansing enemas can be small-volume, eg, 4.5 oz hyperosmostic sodium phosphate or lubricant oil enemas, or large-volume, as in the case of water cleansing enemas ranging from 500 to 1500 mL in volume.

There’s a bit of an art to judging what volume is appropriate for a given patient, and the tolerable volume might change depending on the severity of the patient’s disease state, time of day, most recent meal, and other factors. Patients with UC often experience frequent, loose, and urgent stool, so retaining even small-to-moderate volumes can be challenging. Helping them to find the best time of day and time to administer in relation to eating, as well as managing urgency and frequency with oral interventions – ranging from curcumin and activated charcoal to loperamide, cholestyramine, and prednisone – can assist them in retaining therapeutic enemas for long enough to realize benefit from them.

VITAMIN E

Vitamin E, an antioxidant and anti-inflammatory, acts as a healing nutrient when applied topically. In an open-label trial, 14 patients with mild-to-moderately active distal UC self-administered about half an ounce of d-α-tocopherol (8000 IU) QD for 12 weeks.3 At 4 weeks 21% were in remission, and at 12 weeks 64% were in remission. The erythrocyte sedimentation rate (ESR) dropped 80% during this time. Since this trial was published, I have used vitamin E retention enemas with my patients with distal colonic IBD, either alone or in combination with other rectal therapies. Several patients have experienced discernible improvement over time, which we attribute to the vitamin E enemas.

Summary:
Small-volume, liquid vitamin E retention enemas (8000 IU), when used for 2-12+ weeks, may contribute to remission in patients with distal UC.

COLOSTRUM

Colostrum is an immunoglobulin-rich, post-partum, pre-milk mammary gland secretion that is crucial for the health of newborn mammals. Humans have used bovine colostrum orally for many conditions. In a randomized, double-blinded trial, 14 patients with mild-to-moderately active distal UC self-administered half an ounce of liquid colostrum or a control solution rectally BID for 4 weeks.4 At the end of this time period there was a significant improvement in histological scores in the colostrum group, and at 6 months only 13% of the colostrum group required steroids (vs 50% of the placebo enema group). I have used liquid colostrum enemas in my practice, but not for long enough to comment yet on their efficacy.

Summary:
Small-volume, liquid colostrum retention enemas (half-ounce), when used daily for 4 weeks, appear to significantly improve colon mucosal healing and decrease steroid dependence in patients with distal UC.

CALENDULA

Calendula is one of our best medical herbs. A randomized controlled trial looked at the ability of calendula tea retention enemas to promote colon mucosal healing in dogs with acetic acid-induced UC.5Although they did not carefully report details of benefit in the calendula vs placebo groups, the authors reported “significant mucosal healing” 1 month after the subjects received 7 days of calendula tea enemas. Since reading that report, I have used large-volume (half-liter or more) calendula tea retention enemas daily with quite a few patients with distal and proximal colonic IBD, some of whom have reported discernible decreases in rectal discharge of blood and/or mucus, as well as decreases in abdominal pain using this intervention.

Summary:
Large-volume calendula tea enemas may benefit some patients with active UC.

BUTYRATE

Butyric acid is a short-chain fatty acid generated by colonic bacteria. It is used in enema form to down-regulate inflammation and oxidative stress in the colon, which can be achieved even proximal to the sigmoid using only a 60 mL (100 mM butyrate) enema preparation.6 This decrease in inflammation may promote the tolerance of commensal microbes that is critically lacking in IBD.7

Early open-label and single-blind trials using butyrate enemas reported significant benefit in distal colitis8,9; however, later randomized controlled trials only reported significant benefit over placebo in some subgroups10 or for secondary endpoints,11 or found no benefit compared to placebo.12 I have not yet found butyrate enemas to offer significant benefit for my patients with UC, but I have only used them a few times, and other colleagues have reported meaningful benefit.

Summary:
There is conflicting data for small-volume butyrate enemas in the treatment of active distal colitis. Patients who have had IBD for <6 months and who have high compliance rates for this therapy may be the most likely to achieve benefits,10 including decreased bleeding and urgency.11

PROBIOTICS

Oral and rectal probiotics can help induce and maintain remission in patients with UC.13,14 In my experience, individual response to any given probiotic is highly idiosyncratic, so trial and error is my preferred approach to probiotic selection in IBD. That being said, several probiotic enema trials deserve mention, if nothing else to illustrate the point that probiotic enemas can be a useful intervention for UC patients.

In 1 trial, 5-aminosalicylic acid (5-ASA), alone or with oral Lactobacillus casei, failed to alter colon microflora; however, those interventions along with additional L casei enemas significantly altered colonic flora and Toll-like receptor expression and interleukin levels.15

Another group administered either Lactobacillus reuteri enemas (10 billion CFU per rectum QHS) or placebo enema for 8 weeks to 40 children with active distal UC.16 At 8 weeks, there was significant clinical and histological improvement in the probiotic group, vs no significant change in the placebo group. Clinical remission was reached in 31% of the probiotic enema group and in none of the placebo group.16

Many American clinicians are not familiar with the probiotic E coli Nissle 1917 (aka Mutaflor), which has been used in Europe for IBD and other conditions for almost 100 years. This is because the US Food and Drug Administration does not permit Mutaflor to be imported. Oral preparations compare favorably to mesalamine in achieving and maintaining remission when used in adults17 and children18 with active UC. Mutaflor enemas trend towards greater efficacy than placebo enemas for patients with moderately-active distal UC, with benefit increasing with increased volumes up to 40 mL.19

Bifidobacterium enemas have been given to successfully resolve necrotizing enterocolitis.20 This is not an autoimmune colitis like UC; however, it does demonstrate the ability of Bifidobacteria to safely and effectively alter colon flora to reduce dangerous inflammation.

I routinely prescribe Lactobacillus spp and Bifidobacterium spp probiotics enemas at doses of 10-500 billion CFU for patients with distal UC, and have found them to assist in inducing and maintaining remission.

Summary:
Probiotic enemas may help induce and maintain remission in patients with distal UC. Discovering the best species, dose, and frequency of administration for an individual patient will likely involve some individualized experimentation.

FECAL MICROBIOTA TRANSPLANTATION

Fecal slurry preparations, known as fecal transplant or fecal microbiota transplantation (FMT), have been used orally as “yellow dragon soup” to resolve intractable diarrhea since the 4th century in China.21Autologous and exogenous fecal-derived microbes have been administered via enema for UC and other conditions at least since 1910 in the United States.22 Whole-stool fecal slurry enemas have been used for infectious colitis since at least 1958.23 They have also been used by naturopathic doctors for IBD and other conditions in the United States since at least the 1970s,24 and are now used widely in North America for Clostridium difficile (C diff) infections not responding to standard therapies.25,26 When compared with colonoscopic and naso-duodenal delivery, FMT retention enemas have comparable or superior efficacy at resolving C diff infections.

A systematic review of case series of FMT for IBD, in general, reported a 76% response rate and 63% remission rate following FMT.27 A more recent and thorough systematic review and meta-analysis of FMT for IBD reported that 45% of IBD patients achieved clinical remission following FMT.28 A subgroup analysis of cohort studies demonstrated clinical remission in 22% of patients with UC.28

In an open-label trial, 10 children and young adults with mild-to-moderately active UC were given FMT retention enemas (average 165 mL) for 5 consecutive days.29 Of the 9 patients who were able to retain the enemas, 78% showed a clinical response at 1 week, 33% achieved remission at 1 week, and 67% retained their clinical response at 1 month.

Seventy-five active UC patients were randomized to receive weekly either an enema of 50 mL of FMT or a 50 mL water enema (control group) for 6 weeks.30 At 7 weeks, 24% of those in the FMT group were in remission vs only 5% of those in the placebo group. Stool donated by 1 particular donor led to remission in 39% of recipients, while stool from other donors led to remission in only 10% of the participants, suggesting statistical evidence for donor dependence. Participants with UC for less than 1 year were also significantly more likely to respond. There was no difference in adverse events between the FMT and control groups.30

In my practice, I’ve counseled hundreds of adults and children with IBD on the use of home FMT retention enemas. My observations are similar to those in the literature: following an initial series of one 4.5 oz FMT retention enema per day for 10 more-or-less-consecutive days, I see about a quarter of my patients with UC achieve remission, another half discernibly improve, and the last quarter experience no apparent benefit.

Summary:
FMT retention enemas cannot be prepared or administered by clinicians in North America for any patient other than those with C diff infections not responding to standard therapies31; however, many patients with UC turn to their clinicians for guidance around best practice for home FMT, and for stool donor screening. FMT retention enemas, used daily or weekly for 5 to 10 or more times, are significantly likely to lead to a clinical response, and have a 25% or greater chance of inducing remission within 6 to 10 administrations.

5-AMINOSALICYLIC ACID (5-ASA)

Mesalamine is the prescription 5-ASA (a salicylate derivative) most commonly used in IBD. It acts locally in the gut as a cyclooxygenase (COX)-inhibitor and antioxidant.32 Mesalamine preparations induce intolerance or hypersensitivity reactions in about 8% of patients with UC, and may rarely aggravate UC.33

Mesalamine enemas, used nightly for 12-34 weeks, appear to induce remission in the majority of patients with left-sided UC who are unresponsive or intolerant of other therapies.34 Mesalamine enema is equivalent or superior to oral mesalamine at inducing remission in patients with active left-sided UC, and oral and rectal mesalamine combined appears to be more effective than either individually.35 Mesalamine enema is equivalent (and non-significantly superior) to oral mesalamine at maintaining UC patients in remission.36 Mesalamine enemas may be safer in pregnancy and may have fewer side effects than oral preparations.37

Clinicians may think of mesalamine enema for the two-thirds of IBD patients whose disease is limited to the left side of the colon, but it also offers benefit for patients with disease that extends beyond the splenic flexure.38 The use of suppositories, rectal foams, or liquid enemas is based on the extent of the disease.

Efficacy of enemas does not appear to increase with doses over 1 mg.39 The most common mesalamine enema includes potassium metabisulfite as an inactive ingredient, but there is a sulfite-free version available for patients sensitive to sulfites.

Mesalamine enemas are significantly superior to corticosteroid enemas at inducing and retaining remission40; however, corticosteroid enemas may be indicated if other interventions including mesalamine enemas fail or if individual circumstances warrant.

Summary:
Mesalamine enemas, when used for >3 months at 1 mg per rectum QHS by patients who tolerate 5-ASA derivatives, are likely to induce and help maintain remission for many of the two-thirds of UC patients whose disease is mild or moderate and confined to the left side.

CORTICOSTEROIDS

Before corticosteroids were available, a first attack of UC was fatal about one-third of the time; now that number approaches 0.41 Corticosteroids induce partial or complete remission from IBD about 75% of the time,42 but potential side effects – including osteoporosis,43 osteonecrosis,44 and sleep and mood disturbances45 – limit its use. Corticosteroids are not helpful in maintaining long-term remission once it has been achieved, especially when used for longer than 3 months after induction of remission.46 In addition, as many as 9% of people with IBD may have a steroid allergy.47

In North America, the corticosteroids most commonly used for IBD are prednisone, hydrocortisone, and budesonide. The latter 2 are commonly used as enema preparations. Budesonide is a synthetic corticosteroid with low systemic availability due to high first-pass hepatic metabolism, so it has a greatly diminished side-effect profile.48 As many as one-half of IBD patients who don’t respond to mesalamine enemas may respond favorably to budesonide or hydrocortisone enemas,49 and twice-daily budesonide enemas lead to significantly more complete mucosal healing than once-daily enemas.50

Markers of bone formation fall rapidly within 5 days of starting oral corticosteroids; however, no decrease in bone formation markers occur within 2 weeks of starting prednisolone or hydrocortisone enemas.51

Patients tend to prefer foam over liquid enema preparations, though both are equally effective at inducing remission.52

Summary:
Corticosteroid enemas used for 6 to 8 weeks may induce remission in 50% or more of patients with left-sided UC not responding to 5-ASA enemas. Budesonide (2 mg per rectum BID) is the delivery method most likely to deliver the best outcome.

OTHER THERAPIES

There are other types of therapeutic retention enemas described in the literature for use in UC that I have not had the opportunity or additional training to appropriately use.

Historically, Chinese medicine did not use enemas as a delivery method for botanicals or other therapeutic substances53; however, in the past couple of decades, several authors have reported on the use of Chinese medicine herbal enemas to treat UC with varying degrees of efficacy.54-57 This treatment paradigm and the language of choice of these articles leave this author unable to appropriately assess the use of these therapies.

Alicaforsen, a prescription ICAM-1 inhibitor, given as an enema, is superior to placebo and equivalent to mesalamine enemas at inducing remission in patients with UC for up to 10 weeks, and is significantly superior to placebo and mesalamine at maintaining remission at 30 weeks in patients with moderately-to-severely active distal disease.58 Alicaforsen is approved as an orphan drug in Europe, but is not available in the United States.

A turmeric extract, standardized to 72% curcumin and given as a retention enema (140 mg of NCB-02 in 20 mL of water) QHS for 8 weeks, produced a trend towards more remission compared to placebo enema in patients with mild-to-moderate distal UC. Patients who completed all 8 weeks of therapy experienced significantly more remission (71%) than those in the placebo group (31%).59

Epidermal growth factor, a cytokine found in saliva, urine, and breast milk, given as 100 mL retention enemas (delivering 5 µg of epidermal growth factor) once nightly for 14 days, was able to induce remission in 10/12 patients with mild-to-moderate left-sided UC, whereas a placebo enema consisting of the same delivery medium led to remission in only 1/12.60 Unfortunately, no other groups have replicated these astounding results.

Nicotine retention enemas (3-6 mg nicotine for 4 weeks) may contribute to clinical improvement in patients with UC who don’t improve with corticosteroid or mesalamine enemas, albeit with some mild and transient adverse effects.61 However, they have not been found to induce remission more frequently than placebo enemas in broader UC patient groups.62 Nicotine is contraindicated for patients with CD.

Sodium hyaluronate (a mucosal hydrant and healer) enemas, given for 4 weeks, appear to be safe and may contribute to clinical response and mucosal healing in patients with distal UC.63

Rectal ozone may contribute to more rapid healing in patients with distal UC.64

Conclusion:
One-quarter of 1% of people in the United States have ulcerative colitis.65 For many of them with distal or more extensive colitis, retention enemas may be an excellent and underexamined method to deliver therapeutic liquids, including anti-inflammatory, vulnerary, and microbiota-altering substances. Knowing the value and advantages of these substances when delivered via enema may help clinicians and patients overcome the discomfort felt when talking about rectally-administered therapies.

Note: Originally published in January 2016 by Dr. Mark Davis ND and published NDNR – Naturopathic doctor News and Review, this article has been revised and updated for thoroughness. Dr. Mark Davis ND was interviewed for The Crohn’s And Colitis Summit

Categories
Abdominal Pain CalProctetin Case Study Colonoscopy Colostomy Crohn's Disease Diversion colitis Enemas Fistula Hematochezia(Blood in Stool) Ileostomy Inflammation Pharmaceuticals Supplements Surgery Ulcerative Colitis

Coconut Oil Enemas Saves Woman From Surgery

A new case study* out of Germany was just published in the October 2018 American Journal of Gastroenterology.

A 32-year old woman was experiencing fistulizing Crohn’s Disease complicated with diversion colitis.  Diversion colitis is inflammation of the large intestine brought on after surgical treatment (Usually an ileostomy or colostomy).

In early 2016 her perianal fistula, after not responding to pharmaceutical drugs, was treated with a diverting sigmoidostomy which is when surgery creates an artificial anus in the sigmoid colon.  After the surgery, she initially responded well to ENTYVIO®(vedolizumab), although the symptoms from the fistula did not go away. Just a few months later in late 2016, symptoms increased. This included looser stools, increasingly worse abdominal pain(most patients refer to this as stomach pain), and increased mucus and blood.

“Joel Sprechman wasn’t around when I was diagnosed. If he was, with The Crohn’s and Colitis Summit, I am sure I would have avoided surgery.” – Summit Member

 

She switched to STELARA® (ustekinumab), which did not work for her, and also added topical hydrocortisone.  As this too failed, she tried REMICADE® (infliximab) and the chemotherapy drug Purinethol®(6-MP).  Unfortunately, the disease continued to worsen.  Because of the persisting fistula, a reversal of the sigmoidostomy was not an option. She also failed 5-ASA(Mesalamine usually sold as Asacol® HD, Pentasa®, Lialda™, Apriso®, or Delzicol™and glucocorticoids (Usually prednisone or prednisolone).  Her doctor’s next wanted to try short-chain fatty acid(SCFA) enemas as they have been shown to successfully treat colitis.[1][2] However, they were unable to find a compounding pharmacy offering this therapy.

Since she had failed at least five pharmaceutical options and experienced increasing symptoms of post-surgery, her doctors recommend a proctectomy. This would remove all or part of her rectum. She refused this option.

An October 2020 study found that surgery for Inflammatory Bowel Disease persistently lowers microbiome and metabolome diversity and further increased the instability in the gut microbiome of IBD patients.

I can understand this challenging decision, while some live (mostly) symptom-free post-surgery lives, many continue to experience shitty symptoms. Perhaps she was aware of the following statistics. Up to 75% of those with Crohn’s and up to 45% of those with Ulcerative Colitis will have surgery. Also, post-surgery recurrence rates are up to 60% with Crohn’s Disease and 50% with Ulcerative Colitis, and the fertility rates of women post-surgery are one-third of normal. These numbers are from a 2014 publication. [3]

The diagnosed rates of Inflammatory Bowel Disease have likely significantly increased since 2014. [4]

As she decided to refuse another surgery, she asked her doctors for an alternative option. 100ml of prewarmed Coconut Oil was recommended as a suspension enema. Coconut oil contains fatty acids with relatively short chain length to SCFA’s.[5]

coconut oil enema

Just one week into this alternative treatment, abdominal pain, and mucus in her stools decreased. After another six weeks, blood and mucus completely stopped! After 8 weeks of daily enemas, a sigmoidoscopy showed a clear improvement of inflammation(Both endoscopic and histologic).  After 12 weeks of treatment, all pain was gone, and she was able to return to work and resume physical activities up to four times a week!

Coconut Oil Enemas Saves Woman From Surgery #crohnsdisease #crohns #IBD #colitis Click To Tweet

She has continued daily enemas for 6 months with additional symptom reduction, without any adverse effects.

Endoscopic and histopathological findings of diversion colitis. Representative endoscopic images of the rectum prior (left) and after two (middle) and five (right) months of local coconut oil therapy. Before therapy, spontaneous bleeding, erosions, and fibrin indicated moderate mucosal inflammation. Follow-up endoscopies under treatment with coconut oil demonstrated only low-grade inflammation indicated by reduced vasculature and diffuse erythema.

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I contacted the authors of the study, who do not believe the type of Coconut Oil made a difference. I recommend Dr. Bronner’s organic virgin coconut oil in a glass jar.  I’ve met David Bronner and support their commitment to socially and environmentally responsible products. Like One Great Gut, they are also a B-Corp committed to social and environmental performance, accountability, and transparency. Their products do not contain any genetically modified ingredients/organisms (GMOs), are certified as kosher food, and are also vegan and never tested on animals.

Organic is important as you don’t want unwanted pesticides in your body, especially rectally where the bioavailability is higher. When medicine is delivered rectally it bypasses much of the body’s first-pass metabolism and will reach the circulatory system in greater concentration due to the higher bioavailability of rectal delivery. Glass is important for the same reason as you don’t want unwanted plastics that mix with the coconut oil in your body. Even BPA free plastic is not clean enough, it’s still a plastic you don’t want in your body. I’ve heard doctors refer to BPA-free as BPS(BP-“Sh#t”).

To deliver the coconut oil rectally, you can use an Enema bulb or a stainless steel enema bucket kit. The stainless steel enema bucket is the cleaner solution and allows you to re-use easily for other healing medicines like Slippery Elm, Vitamin E, Aloe Vera Juice, and Probiotics.   Most find the bulb to be more uncomfortable and more difficult to clean. I’d also recommend getting this protector pad. Great to protect your bedding or floors from any potential spills. The protector pad is waterproof, washable, and reusable.  I also used Organic Baby Wipes so you can clean your hand, fingers, and the tube as soon as you’re done.

Lab Testing

I recommend checking your Inflammatory markers throughout the year at regular intervals so you can track your progress. What gets measured gets managed. What gets managed can improve.

Inflammatory markers to track include Calprotectin, a stool test that measures inflammation in the gastrointestinal (GI) tract, C-Reactive Protein which is a blood test marker to test inflammation in the body, and Sed rate, also known as erythrocyte sedimentation rate ( ESR) which is also a blood test used to test inflammation in the body and help monitor the status of inflammation, progression or decline.

Your doctor can order these tests for you or you can order directly from the One Great Gut account at Ultra Lab Tests. This is the first company that not just lets patients order their own labs (and receive the results), but also allows you to submit your receipts to your insurance for billing! Please be sure to check with your insurance, as each company has different rules.

Using the links on this page will allow the lab companies listed below to donate to the One Great Gut Foundation.

Here are the direct links to the tests at Ultra Lab Tests for your convenience:

Sed Rate by Modified Westergren (ESR)
Useful in differentiating inflammatory and neoplastic diseases and as an index of disease severity. CRP is also useful in monitoring inflammatory disease states.

Calprotectin, Stool 
Calprotectin, Stool – Canada
Indicator of inflammation specifically in the GI tract. Clinical Significance Used to diagnose inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, or to differentiate IBD from irritable bowel syndrome (IBS).

C-Reactive Protein Cardiac (hs-CRP)
Also useful in predicting risk for cardiovascular disease

Lactoferrin, Quantitative, Stool
This is an Enzyme-Linked Immunosorbent Assay (ELISA) for measuring concentrations of fecal lactoferrin, a marker for leukocytes. An elevated level is an indicator of intestinal inflammation. The test can be used as an in vitro diagnostic aid to distinguish patients with active inflammatory bowel disease (IBD) from those with noninflammatory irritable bowel syndrome (IBS).

Lactoferrin, Qualitative, Stool
The Lactoferrin IBD-CHEK® is a qualitative (QL) Enzyme Linked Immunosorbent Assay (ELISA) for measuring concentrations of fecal lactoferrin, a marker for leukocytes. A positive level is an indicator of intestinal inflammation. The test can be used as an in vitro diagnostic aid to distinguish patients with active inflammatory bowel disease (IBD) from those with non-inflammatory irritable bowel syndrome (IBS).

Fecal Globin by Immunochemistry (InSure®)
The fecal occult blood test is an immunochromatographic fecal occult blood test that qualitatively detects human hemoglobin from blood in fecal samples. This is a useful screening aid for detecting primarily lower gastrointestinal (G.I.) disorders that may be related to iron deficiency anemia, diverticulitis, ulcerative colitis, polyps, adenomas, colorectal cancers or other G.I. lesions that can bleed. It is recommended for use by health professionals as part of routine physical examinations and in screening for colorectal cancer or other sources of lower G.I. bleeding.

Fecal Globin by Immunochemistry (InSure®), Medicare Screen
The fecal occult blood test is an immunochromatographic fecal occult blood test that qualitatively detects human hemoglobin from blood in fecal samples. This is a useful screening aid for detecting primarily lower gastrointestinal (G.I.) disorders that may be related to iron deficiency anemia, diverticulitis, ulcerative colitis, polyps, adenomas, colorectal cancers or other G.I. lesions that can bleed. It is recommended for use by health professionals as part of routine physical examinations and in screening for colorectal cancer or other sources of lower G.I. bleeding.

Another good company to use is True Health Labs who offer more specialized testing. TrueHealthLabs, founded in 2009, was created by a Doctor to make lab testing directly available to those who are uninsured, underinsured, whose doctor refuses to order tests and those who simply want to make their own healthcare choices. Your results will be sent to you via encrypted email. Turnaround times are usually 3-4 business days, however, more complex tests can take 14+ business days.  TrueHealthLabs  saves you 20-80% off lab tests by negotiating directly with CLIA certified labs. With a very high trust rating from thousands of users I am a fan.

They conveniently accept HSA +FSA Accounts, too! 

Some of these tests are more expensive than your usual test, and that is because they give specific insight into certain lab markers that other labs are not able to see. For example, the last time I tested my

pro-inflammatory IL2-TH1 with lab corp they were only able to tell me that I was under 31.2. Not exactly helpful!! CytoDx, seen below, will show you IL2-TH1 with greater granularity, and since we would like it to be below 12, this further shows that the <31 from the other lab is not very useful information.

Antibodies to Saccharomyces cerevisiae
These are found in approximately 75% of patients with Crohn’s disease, 15% of patients with ulcerative colitis, and 5% of the healthy population. High antibody titers increase the likelihood of disease, especially Crohn’s disease, and are associated with more aggressive disease. As the inflammation in Crohn’s disease is focused at the gut mucosa, most patients have IgA antibodies to S cerevisiae and half of these also have IgG antibodies. A minority of patients have only IgG antibodies to S cerevisiae.

TH1 TH2 Cytokine Test – Basic
For those with a confirmed autoimmune condition, the Th1 Th2 test is possibly the most important test. The test points out imbalances in the immune system by looking at cytokines, proteins that the immune system relies on to communicate. Bad communication results in complications for those with autoimmune conditions. The information this test provides helps your doctor develop a strong and effective treatment plan for you, especially when seeking alternative medicine support.
The immune system works like a seesaw. On one side you have Th1 cytokines that initiate the first line of defense. On the other side, you have Th2 cytokines that help produce antibodies to protect you from future invasions. However, when one side goes up, the other side goes down. This can contribute to a weak immune system and potentially promote autoimmune issues. Running this test will help to understand where the imbalance is. Because certain botanicals used in natural medicine can boost Th1 cytokines and Th2 cytokines, this test can help you and your doctor develop an effective plan to help balance a weak immune system and turn the volume down on autoimmune attacks.

TH1 TH2 TH17 Cytokine Test – Advanced aka CytoDX
This test is more detailed than the above with readings including

  • Inflammatory Cytokines- Th1
    • INF Gamma: Th1
    • IL-1 beta: Th1
    • IL-2: Th1
    • IL-6: Th1 and Th2
    • IL-7: Weak Th1
    • IL-8: Weak Th1
    • IL-12 p70: Th1
    • IL-17A: Th17
    • IL-18: Weak Th1
    • TNF alpha- Th1
  • Anti-Inflammatory Cytokines- Th2
    • IL-4: Th2
    • IL-5: Th2
    • IL-10: T-regulatory cells
    • IL-13: Th2
    • IL-15: Weak Th2

TH17 Test
New studies show that an increase in a particular type of white blood cell, called Th17 cells, can trigger and determine the severity of autoimmune conditions. Monitoring Th17 levels can help you and your doctor better treat the condition.

Basic CD4 CD8 Ratio Test
The CD4 CD8 ratio profile helps assess the immune system in detail. This test is crucial for patients who are suspected of having a compromised immune system as seen in autoimmune conditions and HIV.

I recommend to run the Th1 Th2 test along with this CD4/CD8 ratio test if you have any concerns with an autoimmune condition like Crohn’s or Colitis.

We continually update the IBD Crohn’s Colitis Lab Testing Page You Can Order Without A Doctor. I recommend checking that page to see if there are any tests that may be helpful for your health journey.

Using the links on this page will allow the lab companies to donate to the One Great Gut Foundation.

I hope this has been helpful for your journey towards a Great Gut!

Have you tried a Coconut Oil enema? We’d love to hear from you. Your response can help others heal.  Please comment below, add your story to our research center, or leave us a comment on our Facebook page.

If you find this information useful, please donate so we can continue providing you with meaningful information to help you Thrive with IBD Crohn’s Colitis. Thank You.

References

[1] Harig JM, Soergel KH, Komorowski RA, et al. Treatment of diversion colitis with shortchain-fatty acid irrigation. N Engl J Med. 1989;320:23–28.
[2] Vernia P, Cittadini M, Caprilli R, et al. Topical treatment of refractory distal ulcerative colitis with 5-ASA and sodium butyrate. Dig Dis Sci. 1995;40:305–7
[3] CCFA 2014 Fact Book
[4] CDC Morbidity and Mortality Weekly Report (MMWR) – Prevalence of Inflammatory Bowel Disease Among Adults Aged ≥18 Years — United States, 2015 –  Published October 2016
[5] Orsavova J, Misurcova L, Vavra Ambrozova J, et al. Fatty acids composition of vegetable oils and its contribution to dietary energy intake and dependence of cardiovascular mortality on dietary intake of fatty acids. Int J Mol Sci. 2015;16:12871–90.
Case Study: The American Journal of Gastroenterology: Successful Long-term Treatment of Diversion Colitis with Topical Coconut Oil Application Dec 2018 : Zundler S, Dietz L, Matzel KE, Geppert CI, Becker E, Rath T, Neurath MF, Atreya R

Note: Originally published in October 2018, this article has been revised and updated for accuracy and thoroughness.

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