Physicians of the Zane Cohen Centre

Alternatives: Complementary Therapies and Natural Health Products

Increasingly, alternative therapies are becoming more common and well-known. Individuals may be interested in learning about or trying herbal remedies, diet regimes, or holistic practices such as homeopathy or naturopathy in conjunction with or in isolation of western medical treatments.

The decision to try or utilize alternative therapies is a personal one, but it is recommended that you inform your Family Physician and Specialists of your choice so that they can be aware of any possible interaction between your therapies.

In 2003, the Federal Minister of Health announced the adoption of the Natural Health Products Regulations. Natural Health Products (NHPs) are defined in the Regulations as vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines such as Traditional Chinese Medicines, probiotics, and other products like amino acids and essential fatty acids. Under the new Regulations, the product must be safe for consideration as an over-the-counter (OTC) product. Natural Health Products are available for self-care and self-selection, and do not require a prescription to be sold.

All natural health products in Canada will now require a product licence before being marketed. Obtaining a license will require detailed information about the product submitted to Health Canada, including medicinal ingredients, source, potency, non-medicinal ingredients and recommended use. Once a product has been assessed by Health Canada, the product label will bear a product licence number preceded by the distinct letters NPN, or, in the case of a homeopathic medicine, by the letters DIN-HM. The product licence number on the label will inform consumers that the product has been reviewed and approved by Health Canada for safety and efficacy.

With improved, standardized labelling, consumers will be able to make more informed decisions about the natural health products they buy. Labels will be required to specify directions for use, the recommended use or purpose (health claim), medicinal and non-medicinal ingredients, and any cautions, contra-indications or known adverse reactions associated with the product.

In making health claims, industry relies on a variety of standards of evidence, such as history of use or traditional references, observational studies, expert committee reports and clinical or trial data. However, ongoing research continues to be necessary. To address this need for more research, Health Canada has committed $5 million over 5 years to create the Natural Health Products Research Program. Funding for this program will be drawn from the existing fiscal framework. The Natural Health Products Research Program has been developed over the past 2 years through active dialogue with all relevant stakeholder groups. Working closely in partnership with the community at large and the Canadian Institutes of Health Research, the Natural Health Products Research Program will support the creation of a sustainable national natural health product research presence, which meets the needs of Canadians.

For more information about Natural Health Products Directorate, visit the Health Canada website.

For more information about alternative therapies, visit the National Center for Complementary and Alternative Medicine website on complimentary medicine.

Antidiarrheal Medications

Antidiarrheal medications are prescribed often to control diarrhea caused by Crohn's disease, ulcerative colitis and pouchitis. As a general rule, people with these illnesses should aim for a modest reduction in the number of stools passed, rather than a total elimination of the problem. Overuse of antidiarrheal drugs, for more than 2 or 3 days at a time may lead to serious complications and should only be used under the guidance of a physician or an IBD specialist.

Loperamide (Imodium®) and Diphenoxylate (Lomotil®)

These drugs reduce diarrhea by slowing the rate at which food is propelled through the intestine, allowing more time for bacteria to break down undigested fats and fibre and allowing more time for absorption of fluid and electrolytes. Loperamide also tightens the anal sphincter and helps prevent incontinence. Since these drugs on occasion can paralyse the colonic muscles and lead to serious complications, they should not be used for severe ulcerative colitis and Crohn's disease in the acute situation.

Possible side effects:

  • gas
  • bloating
  • cramps
  • constipation
  • nausea *
  • drowsiness *

* when opioid analgesics such as codeine are used to slow down watery bowel movements

Immunosuppressive Drugs

Immunosuppressive drugs suppress actions of the immune system and its inflammatory response. These drugs are useful for very active IBD that does not respond to standard therapy and help maintain remission. An immunosuppressant is often combined with a steroid to speed up response during active disease. In some instances, an immunosuppressant drug may also be given along with an anti-TNF drug, such a infliximab or adalimumab, in order to further improve upon the short and long term effectiveness of these drugs.

The immunosuppressants used in IBD are azathioprine (Imuran), mercaptopurine (6-MP, Purinethol), methotrexate, and cyclosporine (Neoral, Sandimmune). Patients on immunosuppresive drugs require regular blood tests to monitor for potential adverse effects.

Azathioprine is a prodrug of 6-mercaptopurine. These agents are often used for maintenance therapy of Crohn's disease and for active disease that does not respond to steroids. It is also used for maintenance therapy in patients with ulcerative colitis who cannot take 5-ASA drugs because of side effects or for those patients in whom 5-ASA does not adequately maintain remission. Rare but serious side effects effects of azathioprine and 6-mercaptopurine include: pancreatitis, hepatitis, and bone marrow suppression.

Methotrexate is an effective alternative for patients with Crohn's disease who have failed other treatments and cannot tolerate other immunosuppressive drugs. Its use is limited by its uncommon but serious side effects such as liver damage and lung inflammation.

Cyclosporine, given intravenously, is occasionally used for treatement of severe active ulcerative colitis that is not responding to other therapies. Side effects occur commonly with cyclosporine and the beneficial effect of treatment is often not maintained when patients are switched to the oral form of the drug. Thus, it is not useful in long-term maintenance therapy.

Biologic Response Modifiers

Infliximab (Remicade) is the first genetically-engineered drug to be approved for Crohn's disease and ulcerative colitis. The drug is a specially designed antibody (monoclonal antibody) which acts against tumour necrosis factor (TNF?) — a cytokine associated with the inflammatory process in IBD. Infliximab is given as an intravenous infusion, initially 3 times over 6 weeks and then every 8 weeks.

Trials have shown infliximab can heal fistulas and help patients with moderate to severe Crohn's disease who have not responded to standard treatments. The most common side effects are: headache, chills, and fever associated with the infusion of the drug. Some patients have experienced breathing problems, joint swelling, autoimmune reactions, and increased rates of infections, although these effects are rare. Of concern are reports of some cases of lymphoma (a rare cancer of the lymph glands) and an increased susceptibility to reactivation of tuberculosis infection in people who have been previously exposed to the infection. The risk of tuberculosis can be significantly reduced by screening for the infection before treatment with infliximab and the risk of lymphoma may be related more to the use of other immunosuppressive drugs, such as azathioprine or 6-mercaptopurine, than to infliximab.

Adalimumab (Humira) is also an antibody that has been specially designed to block the action of tumour necrosis factor (TNF?). Adalimumab is given as a subcutaneous injection (under the skin) every second week.

Adalimumab has been approved for use in the treatment of Crohn’s disease, where it has been shown to improve symptoms and induce and maintain remission. There is also data from studies that suggest that it is effective in healing fistulas in Crohn’s disease and in keeping them healed.

The most common side effect with adalimumab is irritation of the skin around the injection site. This is usually mild. As with infliximab there is an increased risk of infections and there have also been reports of lymphoma (a rare cancer of the lymph glands). There is also the potential for reactivation of tuberculosis infection in people who have been previously exposed to the infection. The risk of tuberculosis can be significantly reduced by screening for the infection before treatment with adalimumab and the risk of lymphoma may be related more to the use of other immunosuppressive drugs, such as azathioprine or 6-mercaptopurine, than to adalimumab.

Other biologic response modifiers that alter other aspects of the body's immune response are under investigation.

Antibiotics

Antibiotics are important in controlling the bacterial overgrowth that can sometimes occur in the small intestine in the patients with Crohn's disease. They are also commonly used for treating infections such as abscesses. Antibiotics may also be useful for treating some cases of active Crohn's disease and are commonly used to treat pouchitis in ulcerative colitis patients who have undergone an ileoanal-pouch procedure.

Typical antibiotics are ciprofloxacin (Cipro) and metronidazole (Flagyl). Either antibiotic, used alone or in combination, is effective and can help maintain remission in patients who have experienced repeated episodes of pouchitis. Because patients may be on long-term therapy, antibiotics carry a risk of side effects and drug interactions.

Side Effects of Metronidazole (Flagyl)

  • taste disturbances

  • numbness and tingling of hands and feet

  • nausea

  • decreased appetite

  • flushing and malaise with the use of alcohol

 

Side Effects of Ciprofloxacin (Cipro)

  • nausea

  • susceptibility to the sun: increased risk of sunburn, skin reaction

  • decreased absorption with calcium and iron supplements, antacid

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