Posted on: Saturday, May 4th 2024 at 3:00 am
For the millions worldwide suffering from ulcerative colitis, finding safe and effective treatments can be a daunting task. While conventional medications remain the mainstay of therapy, a growing number of patients are turning to herbal medicines for additional support. Now, a new systematic review and meta-analysis has shed light on which botanical treatments hold the most promise for managing active disease.
Ulcerative colitis (UC), a chronic inflammatory bowel disease affecting the colon, poses significant challenges for patients and healthcare providers alike. While standard treatments such as aminosalicylates, corticosteroids, and biologics can be effective, they are not always tolerated and may have significant side effects.1 As a result, many patients seek out complementary and alternative therapies, including herbal medicines, to help manage their symptoms.2 However, the evidence for these treatments has been limited and sometimes conflicting.
Aiming to clarify the role of herbal medicines in treating active UC, researchers from the United States conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating these interventions.3 The study, published in the journal Nutrients, included 28 RCTs evaluating 18 different herbs.
The researchers, led by Preetha Iyengar of the Johns Hopkins University School of Medicine, searched multiple databases to identify relevant trials. To be included, studies had to be RCTs comparing an herbal medicine to placebo, standard therapy, or another active treatment in patients with active UC. The primary outcomes of interest were clinical response, clinical remission, endoscopic response, and endoscopic remission. Safety data were also collected.
After screening over 2,000 articles, 28 RCTs met the inclusion criteria. The most commonly studied herbs were Curcuma longa (turmeric), Andrographis paniculata, and Indigo naturalis. Pooled analyses revealed some significant findings.
Compared to placebo, Indigo naturalis demonstrated significantly higher rates of clinical response (RR 3.70, 95% CI 1.97-6.95), but not remission. Curcuma longa, on the other hand, did not show a statistically significant benefit for clinical response (RR 1.60, 95% CI 0.99-2.58), but did have significantly higher rates of clinical remission (RR 2.58, 95% CI 1.18-5.63), endoscopic response (RR 1.56, 95% CI 1.08-2.26), and endoscopic remission (RR 19.37, 95% CI 2.71-138.42). Andrographis paniculata did not demonstrate significant benefits for either clinical response or remission compared to placebo.
The dosages of the herbal treatments varied among the studies. For Curcuma longa, daily doses ranged from 450 mg to 3 g of curcumin, the active constituent. Indigo naturalis studies used either 0.5 g or 2 g per day of the powdered herb. Andrographis paniculata doses ranged from 1200 mg to 1800 mg per day of the extract.
Adverse events were generally mild across the studies, with no significant differences seen between the herbal treatments and placebo in most cases. However, the authors note that larger and longer-term studies are needed to fully assess safety.
While these results are promising, particularly for Curcuma longa, the authors caution that the overall quality of evidence was low to very low for most outcomes, largely due to the small size and methodological limitations of many of the included studies. They call for larger, well-designed RCTs to confirm these findings and better establish the optimal dosing and formulation of these herbal medicines.
This study adds to the growing literature on the potential of natural therapies for managing inflammatory bowel diseases like UC. The GreenMedInfo database, a repository of scientific research on natural medicines, lists over 170 substances that have been studied in the context of UC.4 Some of the top researched natural interventions include:
1. Curcumin: The active compound in turmeric, curcumin has well-established anti-inflammatory and antioxidant properties.5 Multiple studies have found it effective for inducing and maintaining remission in UC.6,7
2. Probiotics: Dysbiosis, or imbalance of gut bacteria, is a key feature of UC. Probiotics can help restore a healthy microbiome and reduce inflammation.8 Specific strains like _Escherichia coli_ Nissle 1917 and VSL#3 have shown benefit in UC trials.9,10
3. Omega-3 Fatty Acids: These anti-inflammatory fats, found in fish oil and flaxseed oil, can reduce disease activity and help maintain remission in UC.11,12
4. Aloe Vera: The gel from this common plant has anti-inflammatory effects in the gut and has been found to improve symptoms and induce remission in UC patients.13,14
5. Boswellia: Also known as Indian frankincense, boswellia extracts have potent anti-inflammatory actions and have shown promise in several UC studies.15,16
6. Green Tea: The polyphenols in green tea, particularly epigallocatechin-3-gallate (EGCG), can reduce inflammation and oxidative stress in the colon.17 Clinical trials have found green tea enemas and oral supplements effective for UC.18,19
7. Ginger: This common spice has anti-inflammatory and antioxidant effects that may benefit UC. Animal studies have found it effective for reducing colitis severity.20,21
8. Vitamin D: Low vitamin D levels are common in UC patients and are associated with more active disease.22 Supplementation can reduce inflammation and improve quality of life.23,24
9. Andrographis Paniculata: While the current meta-analysis did not find a significant benefit, other studies have suggested this herb can reduce disease activity and rectal bleeding in UC.25,26
10. Wheatgrass: The juice of this young grass is rich in antioxidants and has been found to reduce disease activity and rectal bleeding in UC patients in several small studies.27,28
As always, patients should consult with their healthcare provider before starting any new treatment, as herbal medicines can interact with other medications and may not be appropriate for everyone. However, with guidance from a knowledgeable practitioner, integrative approaches incorporating both conventional and evidence-based complementary therapies may offer new hope for better managing this challenging condition.
References
1. Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet. 2017 Apr 29;389(10080):1756-1770. doi: 10.1016/S0140-6736(16)32126-2. PMID: 27914657.
2. Cheifetz AS, Gianotti R, Luber R, Gibson PR. Complementary and Alternative Medicines Used by Patients With Inflammatory Bowel Diseases. Gastroenterology. 2017 Feb;152(2):415-429.e15. doi: 10.1053/j.gastro.2016.10.004. Epub 2016 Oct 14. PMID: 27743873.
3. Iyengar P, Godoy-Brewer G, Maniyar I, White J, Maas L, Parian AM, Limketkai B. Herbal Medicines for the Treatment of Active Ulcerative Colitis: A Systematic Review and Meta-Analysis. Nutrients. 2024 Mar 23;16(7):934. doi: 10.3390/nu16070934. PMID: 38612967; PMCID: PMC11013716.
4. GreenMedInfo.com. Ulcerative Colitis. https://greenmedinfo.com/
5. Jurenka JS. Anti-inflammatory properties of curcumin, a major constituent of Curcuma longa: a review of preclinical and clinical research. Altern Med Rev. 2009 Jun;14(2):141-53. PMID: 19594223
6. Lang A, Salomon N, Wu JC, Kopylov U, Lahat A, Har-Noy O, Ching JY, Cheong PK, Avidan B, Gamus D, Kaimakliotis I, Eliakim R, Ng SC, Ben-Horin S. Curcumin in Combination With Mesalamine Induces Remission in Patients With Mild-to-Moderate Ulcerative Colitis in a Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2015 Aug;13(8):1444-9.e1. doi: 10.1016/j.cgh.2015.02.019. Epub 2015 Feb 26. PMID: 25724700.
7. Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama Y, Andoh A, Tsujikawa T, Fujiyama Y, Mitsuyama K, Sata M, Yamada M, Iwaoka Y, Kanke K, Hiraishi H, Hirayama K, Arai H, Yoshii S, Uchijima M, Nagata T, Koide Y. Curcumin maintenance therapy for ulcerative colitis: randomized, multicenter, double-blind, placebo-controlled trial. Clin Gastroenterol Hepatol. 2006 Dec;4(12):1502-6. doi: 10.1016/j.cgh.2006.08.008. Epub 2006 Nov 3. PMID: 17101300.
8. Mack DR. Probiotics in inflammatory bowel diseases and associated conditions. Nutrients. 2011 Feb;3(2):245-64. doi: 10.3390/nu3020245. Epub 2011 Feb 17. PMID: 22254095; PMCID: PMC3257658.
9. Kruis W, Fric P, Pokrotnieks J, Lukás M, Fixa B, Kascák M, Kamm MA, Weismueller J, Beglinger C, Stolte M, Wolff C, Schulze J. Maintaining remission of ulcerative colitis with the probiotic Escherichia coli Nissle 1917 is as effective as with standard mesalazine. Gut. 2004 Nov;53(11):1617-23. doi: 10.1136/gut.2003.037747. PMID: 15479682; PMCID: PMC1774300.
10. Tursi A, Brandimarte G, Papa A, Giglio A, Elisei W, Giorgetti GM, Forti G, Morini S, Hassan C, Pistoia MA, Modeo ME, Rodino' S, D'Amico T, Sebkova L, Sacca' N, Di Giulio E, Luzza F, Imeneo M, Larussa T, Di Rosa S, Annese V, Danese S, Gasbarrini A. Treatment of relapsing mild-to-moderate ulcerative colitis with the probiotic VSL#3 as adjunctive to a standard pharmaceutical treatment: a double-blind, randomized, placebo-controlled study. Am J Gastroenterol. 2010 Oct;105(10):2218-27. doi: 10.1038/ajg.2010.218. Epub 2010 Jun 1. PMID: 20517305; PMCID: PMC3180711.
11. Barbosa DS, Cecchini R, El Kadri MZ, Rodríguez MA, Burini RC, Dichi I. Decreased oxidative stress in patients with ulcerative colitis supplemented with fish oil omega-3 fatty acids. Nutrition. 2003 Oct;19(10):837-42. doi: 10.1016/s0899-9007(03)00162-x. PMID: 14559319.
12. Stenson WF, Cort D, Rodgers J, Burakoff R, DeSchryver-Kecskemeti K, Gramlich TL, Beeken W. Dietary supplementation with fish oil in ulcerative colitis. Ann Intern Med. 1992 Apr 15;116(8):609-14. doi: 10.7326/0003-4819-116-8-609. PMID: 1312317.
13. Langmead L, Feakins RM, Goldthorpe S, Holt H, Tsironi E, De Silva A, Jewell DP, Rampton DS. Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis. Aliment Pharmacol Ther. 2004 Apr 1;19(7):739-47. doi: 10.1111/j.1365-2036.2004.
14. Langmead L, Makins RJ, Rampton DS. Anti-inflammatory effects of aloe vera gel in human colorectal mucosa in vitro. Aliment Pharmacol Ther. 2004 Mar 1;19(5):521-7. doi: 10.1111/j.1365-2036.2004.
15. Gupta I, Parihar A, Malhotra P, Singh GB, Lüdtke R, Safayhi H, Ammon HP. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res. 1997 Jan;2(1):37-43. PMID: 9049593.
16. Madisch A, Miehlke S, Eichele O, Mrwa J, Bethke B, Kuhlisch E, Bästlein E, Wilhelms G, Morgner A, Wigginghaus B, Stolte M. Boswellia serrata extract for the treatment of collagenous colitis. A double-blind, randomized, placebo-controlled, multicenter trial. Int J Colorectal Dis. 2007 Dec;22(12):1445-51. doi: 10.1007/s00384-007-0364-1. Epub 2007 Aug 1. PMID: 17668137.
17. Chen D, Wan SB, Yang H, Yuan J, Chan TH, Dou QP. EGCG, green tea polyphenols and their synthetic analogs and prodrugs for human cancer prevention and treatment. Adv Clin Chem. 2011;53:155-77. doi: 10.1016/b978-0-12-385855-9.
18. Maity S, Ukil A, Karmakar S, Datta N, Chaudhuri T, Vedasiromoni JR, Ganguly DK, Das PK. Thearubigin, the major polyphenol of black tea, ameliorates mucosal injury in trinitrobenzene sulfonic acid-induced colitis. Eur J Pharmacol. 2003 Jul 11;470(1-2):103-12. doi: 10.1016/s0014-2999
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