– Although the new ulcerative colitis guidelines make no current recommendations on probiotics and curcumin because of gaps in knowledge, both may be beneficial today in selected patients, an expert said at the meeting jointly provided by Rutgers and Global Academy for Medical Education.

Dr. Steven R. Brant, chief in the division of gastroenterology and hepatology at Robert Wood Johnson Medical School, New Brunswick, N.J. Andrew D. Bowser/MDedge News

Dr. Steven R. Brant

“Probiotics can be added, in my opinion, to patients on mesalamine with mild to moderate ulcerative colitis in order to help induce remission without having to go to immunosuppressive medication,” said Steven R. Brant, MD, chief of the division of gastroenterology and hepatology at Robert Wood Johnson Medical School, New Brunswick, N.J.

Likewise, curcumin has shown “minimal harm” in mild ulcerative colitis and may help nudge patients toward disease control without having to resort to corticosteroids or other immunosuppressive therapy, Dr. Brant said.

The new American Gastroenterological Association guidelines for treatment of mild to moderate ulcerative colitis, published in February in the journal Gastroenterology, declined to make recommendations on either probiotics or curcumin, citing “knowledge gaps and areas for future research.”

“Although these modalities appear to be safe, their use risks delaying proven effective therapy with the potential for worsening symptoms or complications,” Cynthia W. Ko, MD, and guideline coauthors said in the recommendations.

From the patient perspective, probiotics are “popular,” Dr. Brant said in his presentation, noting that some patients will request probiotics as a first-line therapy or even ask to be taken off mesalamine and put on probiotics.

Meta-analyses have provided differing conclusions on the benefits of probiotics. One recently published analysis of probiotics versus mesalamine showed a slight trend to favor mesalamine, but when looking at good-quality studies only, the meta-analysis showed a nonsignificant trend in favor of probiotics, Dr. Brant said.

By contrast, in a Cochrane meta-analysis of mesalamine at standard doses versus placebo, there was consistent evidence for a benefit of mesalamine: “so the main problem with giving probiotics as a choice is that you’re going to put the patient at risk for progressive symptoms and complications,” said Dr. Brant.

However, looking specifically at the probiotic VSL#3, the Toronto Ulcerative Colitis Consensus Group said that it was linked to significantly improved remission (44% vs. 25%; odds ratio, 2.4; P = .0007). Coverage issues could be a snag, since the amount of the probiotic associated with improved remission was equivalent to four double-strength packets. “Try getting that approved,” Dr. Brant told attendees. “You’ll have some challenges.”

Curcumin was evaluated in a multicenter trial showing that, when added to maximal mesalamine, it may be helpful in avoiding an advance in therapy, with 54% achieving clinical remission at week 4 versus 0% of placebo-treated patients.

That was a “reasonable study” but more research needs to be done, Dr. Brant said.

“I think that given the minimal harm, it may be worth a trial, though not in patients that are really having systemic symptoms, severe bleeding, and are getting worse,” he said. “It’s patients that have some response on mesalamine where it may be valuable, if you have time to spare to give them curcumin.”

Dr. Brant indicated that he had no relevant financial relationships to disclose.

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