First-line treatments for ulcerative colitis generally consist of 5aminosalysilic acids (5ASA) medications. Yet roughly 50% of patients don’t respond to 5ASA and are subsequently escalated to immune-suppressing medications or anti-TNF therapy. But even these are limited in efficacy and are linked to a myriad of adverse effects.
Understandably, patients and researchers alike are seeking more natural and integrative solutions for IBD. The resulting clinical interest in natural compounds has led to what some might call a renaissance of herbal medicine within the mainstream healthcare system.
Herbs used in Traditional Chinese Medicine (TCM) have garnered much clinical interest for their efficacy in ulcerative colitis, and have undergone substantial research. Of note are the herbal agents aloe vera, Andrographis paniculata extract, Boswellia, xilei-san enema, qing dai powder, and curcumin.
Researchers have investigated the efficacy of these agents both as sole therapies or in combination with standard medication as an integrative treatment for UC. After screening through all the research and clinical trials, our team focused on the most promising agents, and continued their development into innovative formulations that could be used safely and effectively in IBD.
We’ve found considerable success with an integrative approach in our own clinics and hospitals, as illustrated in the case report below.
Herbal Agents for UC: A Case Report
Several years ago, a twenty-five-year-old patient with extensive UC (pancolitis) was referred by her gastroenterologist to the integrative medicine unit in our department. She’d been diagnosed eight years prior, at the age of seventeen, and had been treated with oral and topical 5ASA medication as well as azathioprine. And yet she continued to suffer periodic flare-ups.
Her colonoscopy showed severe inflammation involving her entire colon, elevated C-reactive protein (CRP), and platelet count. After an increase of azathioprine (an immunosuppressant drug) failed to improve her condition, she was started on infliximab (a biological drug used in autoimmune diseases) combined with azathioprine and mesalamine. She initially responded well, aside from two flare-ups which were attributed to “opportunistic infections” (infections those with weakened immune systems due to the use of immunosuppressive treatments are more vulnerable to).
She discontinued infliximab after fifteen months of treatment and continued azathioprine and mesalamine with good clinical response. After a year, an additional flare-up required the reintroduction of infliximab. The patient initially responded, but after the first infusion, she lost response to treatment, even when her infliximab dose was doubled.
When I met her, the patient suffered from 6-8 bowel movements a day, with noticeable bleeding, severe urgency, and spasmodic abdominal pain. She’d discontinued azathioprine and infliximab, remaining only on mesalamine. Her CRP level was 7.42, platelets 531, and hemoglobin 11.5. Her most recent sigmoidoscopy, a month prior, showed moderate-severe inflammation of the sigmoid colon graded as endoscopic Mayo score 2.
We started her treatment with qing dai (QD) capsules and a novel curcumin composition (Cur-cure™, 3gr’/day). After two weeks, she reported a significant improvement in her symptoms. After six weeks she reported a complete resolution of her symptoms and was advised to perform a fecal calprotectin test to assess mucosal healing. Twelve weeks into treatment, her fecal calprotectin level was 30, indicating inactive inflammation. After six months of treatment, she underwent a full colonoscopy which showed significant improvement, with most of the colon showing mucosal healing.
This case report demonstrates how a moderate-to-severe case of UC can be effectively treated in an integrative model, but it is just one of many. There is growing evidence of the efficacy of herbal compounds and herbal formulas.
Qing Dai for UC
Qing dai (indigo tinctoria) has been used to treat many bleeding conditions, including colitis. Recently, the herbal compound has been studied for various inflammatory diseases. In vivo, Xiao et al. showed that Qing dai powder could improve inflammatory responses in an experimental model of colitis.
In 2019, Suzuki et al. published a series of case reports of UC patients who were treated concomitantly with QD with promising results. An earlier pilot open-label clinical study by Sugimoto et al. showed that QD was effective in reducing both clinical and endoscopic disease activity in mild-moderate UC patients.
Curcumin for UC
Curcumin is an active phytochemical compound derived from the common spice turmeric (Jiang huang). The compound has undergone extensive studies over the decades as a treatment for cancer, wound healing, neurodegenerative diseases, and more recently, IBD.
The first randomized controlled trial investigated curcumin as an add-on treatment to mesalamine for UC patients in clinical remission. During the initial six-month treatment, only 2 of the 43 patients on curcumin experienced disease relapse compared to 8 of the 39 treated with placebo (P=.040).
In 2014, my research team and I conducted a randomized placebo-controlled trial in which we used an integrative model with curcumin add-on therapy to optimize 5ASA treatment. UC patients with mild-moderate active disease who were failing 5ASA were treated with 3 gr’ per day of curcumin or placebo. Curcumin was shown to be superior in inducing clinical and endoscopic remission over four weeks.
With the ever-growing evidence from clinical trials and practice, we believe a systematic clinical model is warranted in order to integrate these therapies into mainstream medicine.
Nir Salomon
