MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are being tried as well, Dr. Joshua R. Korzenik said.
Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
▸ Probiotics. Most study findings on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced positive results.
The study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and who subsequently developed a chronic inflammatory process, a problem occuring in about 15% of J-pouches. Antibiotics can control the pouchitis, but long term they are not ideal.
The researchers brought the patients' pouchitis into remission with antibiotics, then discontinued the antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3 and assigned another 20 patients to placebo. The pouchitis returned in all of the patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).
Typical probiotics found in health food stores contain between 1 and 20 billion bacteria per gram. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria per gram, and patients in the study took three capsules a day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston, noted.
The VSL#3 treatment regimen costs about $12–$15 per day and is not covered by insurance.
▸ Parasites. Some researchers have speculated that the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, and that this contributes to the development of Crohn's disease and ulcerative colitis. Reintroducing these to the body might help treat these diseases, Dr. Korzenik.
In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90). The disease responded to the treatment in 79% of the patients, and 72% of them achieved remission. “The results are almost too good to be true, but it's promising,” he said.
A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.
The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated.
▸ Fecal transplants. This treatment, also called “human probiotics” because the implanted bacteria come from donor stool, is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection to reestablish normal flora.
In an open-label study of six patients with long-standing ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7).