Whats New in The Understanding Of The Immunology Of Ulcerative Colitis?
IBD’s are characterised by wasting and chronic intestinal inflammation induced by many different cytokine-mediated pathways. It is clearly recognised that medical and surgical interventions do not cure Crohn’s disease because relapse is the rule after remission.
Until a few years ago, IBD was classified into Th1-dependent, that is, Crohn’s disease, and Th2-dependent, that is, ulcerative colitis, phenotypes. However, in recent years, it has been shown that new T-cell subclasses, that is, Th17 and regulatory T cells (TR), exist independently of Th1 and Th2 and that they play a central role in modulating IBD.
Comment
The role of alternative interventions – non pharmacological – are reviewed in terms of their likelihood of success in relation to ulcerative colitis
Ulcerative colitis (UC)
Is a disease of unknown etiology characterised by inflammation of the mucosa and occasionally the submucosa of the colon. Conventional drug therapy for ulcerative colitis involves use of aminosalicylates, corticosteroids, azathioprine/6-mercaptopurine, cyclosporine and anti-tumor necrosis factor therapy. Alternative therapies include probiotics, nicotine and fish oil. Absence of enteric parasites in the developed world and defective mucosal defence mechanisms are some of the hypotheses behind the pathogenesis.
Probiotics
Modulate the immune system in the gut by inducing protective cytokines and suppressing proinflammatory cytokines. Trials have shown their benefit in preventing relapse in UC. E. coli 1917 Nissle was as effective as 5-ASA in preventing relapse [Rembacken et al. 1999]. A combination of eight species of bacteria called VSL#3, in combination with balsalazide, was slightly more effective than balsalazide or mesalamine alone in mild-to-moderate ulcerative colitis[Tursi et al. 2004]. Lactobacillus GG was shown to be more effective then mesalamine in prolonging relapse free time in ulcerative colitis [Zocco et al. 2006].
Saccharomyces Boulardii
In ulcerative colitis, a preliminary trial showed Saccharomyces boulardii to be effective in treatment [Guslandi M etal 2003] A group of 25 patients with a mild to moderate clinical flare-up of ulcerative colitis received additional treatment with S. boulardii 250 mg three times a day for 4 weeks during maintenance treatment with mesalazine. These patients were unsuitable for steroid therapy. Before and after treatment, Rachmilewitz’s clinical activity index was calculated. The probiotic treatment was considered a therapeutic success only when the final score was lower than 6. Of the 24 patients who completed the study, 17 attained clinical remission; this was confirmed endoscopically. These preliminary results suggest that S. boulardii can be effective in the treatment of ulcerative colitis.
Fish Oil
Patients with active ulcerative colitis have increased levels of leukotriene B4 in their rectal mucosa. Eicosapentaenoic acid (EPA) derived from fish oil inhibits leukotriene activity. One study showed that fish oil dietary supplementation results in clinical improvement of active mild-to-moderate ulcerative colitis but is not associated with a significant reduction in mucosal leukotriene B4 production, compared with placebo therapy [Aslan and Triadafilopoulos, 1992].
A double blind placebo controlled crossover trial of 24 patients with active ulcerative colitis showed reductions in rectal dialysate leukotriene B4 levels, improvements in histologic findings, and weight gain [Seidner et al. 2005; Stenson et al. 1992].
Another randomised controlled trial showed that a fish oil-enriched oral supplement significantly decreased the dose of prednisone required to control clinical symptoms [Seidner et al. 2005]. The dose of fish oil (0.18 g EPA/capsule) is 15-18 capsules per day. The large number of capsules as well as the development of a fishy odour in the breath might reduce patient compliance. Nordic Naturals produce fish oils supplements that are designed to prevent the rsk of odour and repeating, making compliance much easier.
Trichuris Suis
Ulcerative colitis is rare in developing countries. A higher rate of helminth infections and colonisation is thought to be a potential reason for this. Chronic helminthic infections cause persistent immune activation that results in hyporesponsiveness and anergy [Borkow et al. 2000]. This impaired immune function may diminish the capacity of these individuals to mount an immune response and hence decrease the risk of ulcerative colitis.
One study looked at 54 patients with active Ulcerative Colitis who were randomly assigned to ingestion of Trichuris suis ova or placebo for 12 weeks. Improvement in disease activity occurred in 43.3% patients with ova treatment compared with 16.7% patients given placebo [Summers et al. 2005]. Additional studies are needed to further evaluate this option. Other groups are also looking at worm therapy as a viable alternative to immunosuppressive medication.
Related articles:
- Phosphatidylcholine (PC) Controls Inflammation in Ulcerative Colitis
- Probiotics and Prebiotics in the Management of Ulcerative Colitis
- A Novel Approach to Treating Depression – How Probiotics Can Shift Mood by Modulating Cytokines
- High Levels of Mercury in Fish – Found in USA Streams
- Bonnie Bassler on how bacteria “talk”
Keywords:bacteria, CAM, cytokines, diet, dysbiosis, EFAs, evidence, fatty acids, gut, gut health, immune, immunity, inflammation, microbiome, mucosal, nutrition, probiotics, regulatory T cells, research, treatment, ulcerative colitis
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