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Combining Therapies For Optimal Results Complementary and Integrative Care for Inflammatory Bowel Disease Gary Weiner, N.D., L.Ac. Pearl Natural Health.

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Presentation on theme: "Combining Therapies For Optimal Results Complementary and Integrative Care for Inflammatory Bowel Disease Gary Weiner, N.D., L.Ac. Pearl Natural Health."— Presentation transcript:

1 Combining Therapies For Optimal Results Complementary and Integrative Care for Inflammatory Bowel Disease Gary Weiner, N.D., L.Ac. Pearl Natural Health

2 Why Am I Here? Because there are two sides to every coin…

3 Goals of Presentation Describe the rationale for integrative care Describe the rationale for integrative care Help you understand what we are doing with your patients when they visit our clinics Help you understand what we are doing with your patients when they visit our clinics Show examples of the care provided Show examples of the care provided Convey what we are telling your patients when they seek our help Convey what we are telling your patients when they seek our help

4 Definitions Alternative Medicine: Alternative Medicine: ”Healing arts not taught in traditional western medical schools that promote options to conventional medicine that are not taught in these schools…” (medterms.com,2013) ”Healing arts not taught in traditional western medical schools that promote options to conventional medicine that are not taught in these schools…” (medterms.com,2013) “Alternative” refers to using a non-mainstream approach in place of conventional medicine (nih.gov 2013). “Alternative” refers to using a non-mainstream approach in place of conventional medicine (nih.gov 2013).

5 Definitions Complementary Medicine: Complementary Medicine: “A group of diagnostic and therapeutic disciplines that are used together with conventional medicine. (medterms.com 2013) “A group of diagnostic and therapeutic disciplines that are used together with conventional medicine. (medterms.com 2013) “Complementary” generally refers to using a non-mainstream approach together with conventional medicine (nih.com 2013) “Complementary” generally refers to using a non-mainstream approach together with conventional medicine (nih.com 2013)

6 Definitions “Integrative Medicine” “Integrative Medicine” The integration into care of an array of “non-mainstream” approaches (nih.gov). The integration into care of an array of “non-mainstream” approaches (nih.gov).

7 CAM and IBD

8 “Patients using CAM report benefits that extend beyond simply improved disease control. Using CAM allows patients to exert a greater degree of control over their disease and its management than they are afforded by conventional medicine. There is limited evidence of the efficacy of CAM therapies in IBD. It is important for physicians caring for those with IBD to be familiar with common forms of CAM and to be able to provide general counseling to their patients about CAM use...”

9 Treatment Decisions Conventional Medical Plan Conventional Medical Plan OR Alternative Medical Plan Alternative Medical Plan

10 Integration “Combining parts so that they work together, or form a whole…” Conventional Medical Plan Conventional Medical Plan Complementary Medical Plan Signs Symptoms “Combining parts so that they work together, or form a whole…”

11 Integration Conventional Medical Plan Conventional Medical Plan Complementary Medical Plan Signs Symptoms Integrative Plan

12 The Integrative Approach The disease is treated in the context of the patient’s total health The disease is treated in the context of the patient’s total health

13 Patients at CAM Clinics Refractory cases Refractory cases Often feel they are not presented with any options Often feel they are not presented with any options Desire control, want to play a role in their care Desire control, want to play a role in their care Fearful of the next step being presented Fearful of the next step being presented Often presenting as a medication fails, wanting to avoid the immunosuppressants or biologics. Often presenting as a medication fails, wanting to avoid the immunosuppressants or biologics. Dissatisfied with side effects or level of wellness on their plan Dissatisfied with side effects or level of wellness on their plan

14 Principles of Integration Integrate therapies that create the conditions for healing Integrate therapies that create the conditions for healing Identify and treat the cause Identify and treat the cause First, do no harm First, do no harm Provide education Provide education Engage in prevention Engage in prevention Treat the “whole” person Treat the “whole” person

15 IMPLEMENT MOST EFFECTIVE DIETARY STRATEGY IMPLEMENT MOST EFFECTIVE DIETARY STRATEGY REMOVE OBSTACLE: DYSBIOSIS REMOVE OBSTACLE: IMMUNE DYSREGULATION REMOVE OBSTACLE : INTESTINAL PERMEABILITY REMOVE OBSTACLE: NUTRITIONAL INSUFFICIENCIES REMOVE OBSTACLE: STRESSORS REMOVE OBSTACLE: SUB-OPTIMAL DIGESTION REMOVE OBSTACLE: ADRENAL HYPOFUNCTION REMOVE OBSTACLE: PSYCHO- EMOTIONAL ` ` PROMOTE HEALTHY LIFESTYLE TREAT THE WHOLE PERSON PROVIDE NECESSARY SUPPORT MONITOR RESPONSES CAREFULLY MONITOR RESPONSES CAREFULLY Integrative Treatment Paradigm

16 “Recent evidence suggests that specific changes in dietary have led to a shift in the composite human gut microbiota resulting in the emergence of pathobionts that can thrive under specific conditions, in the genetically susceptible host…” “Since the gut microbiota is plastic and responds to dietary modulations, the use of probiotics, prebiotics, and/or dietary alterations are all intriguing complementary therapeutic approaches to alleviate IBD symptoms…” “However, the interactions are complex and it is unlikely that a one-size-fits all approach can be utilized across all population…as we move towards an era of personalized medicine to treat IBD…”

17 Implement Dietary Strategy w “Paleolithic” Diet Hypoallergenic Diet Anti- Inflammatory Diet Standard American Diet (SAD) Specific Carbohydrate Diet (SCD) Individualized Diet Formal support to make the transition Food as medicine: which strategy promotes symptom reduction and mucosal healing?

18 This case series indicates the potential for the IBD-AID to be used as an adjunctive or alternative therapy for the treatment of IBD. Notably 9 our of 11 patients were able to be managed without anti-TNF therapy and 100% of the patients had their symptoms reduced. To make clear recommendations for its use in clinical practice, randomized trials are needed alongside strategies to improve acceptability and compliance with the IBD-AID.

19 Dietary Strategy Implementation Start simple  Start simple  Calm down disease expression  Calm down disease expression  Build diet in complexity  Build diet in complexity  Sensitize patient to learn what serves him/her best  Sensitize patient to learn what serves him/her best  Provide clinical support as a program Provide clinical support as a program

20 TREATMENTS: Conventional drug therapies Herbal Meidicines Low Dose Naltrexone Down-regulatory strategies TREATMENTS: Acupuncture Chinese herbal therapies Ayurvedic medicine Homeopathy TREATMENTS: Dietary strategy Anti-microbial therapy Fecal transplant Proiotics Pre-biotics TREATMENTS: Hormone augmentation Adrenal treatments Stress reduction Counseling TREATMENTS: Herbs Enzymes Betaine Hydrochloride Dietary strategy TREATMENTS: Anti-Inflammatory therapies TREATMENTS: Dietary strategy Treatment of deficiencies Nutritional IV Supplements IMPLEMENT MOST EFFECTIVE DIETARY STRATEGY IMPLEMENT MOST EFFECTIVE DIETARY STRATEGY REMOVE OBSTACLE: DYSBIOSIS REMOVE OBSTACLE: IMMUNE DYSREGULATION REMOVE OBSTACLE : INTESTINAL PERMEABILITY REMOVE OBSTACLE: NUTRITIONAL INSUFFICIENCIES REMOVE OBSTACLE: STRESSORS REMOVE OBSTACLE: SUB-OPTIMAL DIGESTION REMOVE OBSTACLE: ADRENAL DYSFUNCTION REMOVE OBSTACLE: PSYCHO- EMOTIONAL ` ` PROMOTE HEALTHY LIFESTYLE TREAT THE WHOLE PERSON PROVIDE NECESSARY SUPPORT MONITOR RESPONSES CAREFULLY MONITOR RESPONSES CAREFULLY

21 Remove Obstacle: Dysbiosis Make attempts to Identify disruption of microbiota: bacteria, fungi, parasites Make attempts to Identify disruption of microbiota: bacteria, fungi, parasites Use stool, saliva, breath; antigen, antibody, other markers Use stool, saliva, breath; antigen, antibody, other markers Treat any findings; use both pharmaceuticals and botanicals (fecal transplants, “worm” therapy) Treat any findings; use both pharmaceuticals and botanicals (fecal transplants, “worm” therapy) Nourish healthy flora Nourish healthy flora VSL#3 VSL#3 Other probiotics Other probiotics Prebiotics Prebiotics

22 Remove Obstacle: Immune Dysregulation Downregulate an upregulated immune system Downregulate an upregulated immune system Treat the dysbiosis Treat the dysbiosis Treat any toxicity that can be quantified; do general detoxification protocols Treat any toxicity that can be quantified; do general detoxification protocols Decrease intestinal permeability with optimal diet Decrease intestinal permeability with optimal diet Use supportive supplements Use supportive supplements Consider Low Dose Naltexone (LDN) Consider Low Dose Naltexone (LDN)

23 Remove Obstacle: Adrenal “Dysfunction” Assess adrenal function Assess adrenal function Salivary test: 4-point cortisol, dhea-s, pregnenalone Salivary test: 4-point cortisol, dhea-s, pregnenalone 24 hour urine 24 hour urine ACTH stimulation ACTH stimulation Blood tests Blood tests Treat any adrenal imbalance Treat any adrenal imbalance Consider restoration of cortisol adequacy as treatment strategy (i.e., low dose cortef or compounded hydrocortisone Consider restoration of cortisol adequacy as treatment strategy (i.e., low dose cortef or compounded hydrocortisone

24 Remove Obstacle: Intestinal Permeability Quantify degree of permeability Quantify degree of permeability Remove allergens from diet Remove allergens from diet Remove pathogens that can be isolated Remove pathogens that can be isolated Build mucosal integrity Build mucosal integrity

25 Remove Obstacle: Sub-optimal digestion Support all phases of digestion Support all phases of digestion Use laboratory to assess absorption & malabsorption, digestion of carbohydrates, lipids, proteins Use laboratory to assess absorption & malabsorption, digestion of carbohydrates, lipids, proteins Address constipation Address constipation Use supports such as betaine hydrochloride, amylases, lipases and proteases, herbs, supplemental oils, acupuncture, and other therapies as necessary Use supports such as betaine hydrochloride, amylases, lipases and proteases, herbs, supplemental oils, acupuncture, and other therapies as necessary

26 Remove Obstacle: Nutritional Deficiencies &Insufficiencies Perform complete nutritional assessment Perform complete nutritional assessment Treat all demonstrated or suspected deficiencies and insufficiencies. Treat all demonstrated or suspected deficiencies and insufficiencies. Through diet, if possible (often problematic) Through diet, if possible (often problematic) Through oral supplementation, if possible (often problematic) Through oral supplementation, if possible (often problematic) Through nutritional IV therapy Through nutritional IV therapy

27 Remove Obstacle: Stressors/Psycho-Emotional Issues Perform stress survey Perform stress survey Counsel toward removal of environmental, physical, psychological, and social stressors Counsel toward removal of environmental, physical, psychological, and social stressors Evaluate adrenal health Evaluate adrenal health Provide or refer to supportive therapies or programs Provide or refer to supportive therapies or programs Consider Mindfulness-Based Stress Reduction (MBSR) Consider Mindfulness-Based Stress Reduction (MBSR)

28 “We believe that providing these services in a GI practice could be cost effective in the long run by potentially decreasing use of our resources and time, such as fewer office visits, emergency room visits, and telephone calls…”

29 TREATMENTS: Conventional drug therapies Herbal Meidicines Low Dose Naltrexone Down-regulatory strategies TREATMENTS: Acupuncture Chinese herbal therapies Ayurvedic medicine Homeopathy TREATMENTS: Dietary strategy Anti-microbial therapy Fecal transplant Proiotics Pre-biotics TREATMENTS: Hormone augmentation Adrenal treatments Stress reduction Counseling TREATMENTS: Herbs Enzymes Betaine Hydrochloride Dietary strategy TREATMENTS: Anti-Inflammatory therapies TREATMENTS: Dietary strategy Treatment of deficiencies Nutritional IV Supplements IMPLEMENT MOST EFFECTIVE DIETARY STRATEGY IMPLEMENT MOST EFFECTIVE DIETARY STRATEGY REMOVE OBSTACLE: DYSBIOSIS REMOVE OBSTACLE: IMMUNE DYSREGULATION REMOVE OBSTACLE : INTESTINAL PERMEABILITY REMOVE OBSTACLE: NUTRITIONAL INSUFFICIENCIES REMOVE OBSTACLE: STRESSORS REMOVE OBSTACLE: SUB-OPTIMAL DIGESTION REMOVE OBSTACLE: ADRENAL HYPOFUNCTION REMOVE OBSTACLE: PSYCHO- EMOTIONAL ` ` PROMOTE HEALTHY LIFESTYLE TREAT THE WHOLE PERSON PROVIDE NECESSARY SUPPORT MONITOR RESPONSES CAREFULLY MONITOR RESPONSES CAREFULLY

30 Evaluation in Integrative Setting Medical History: establish the role of IBD in the context of total health with special attention to diet, nutritional status, life- style considerations, stressors, adrenal health, evidence of dysbiosis, and general wellness Medical History: establish the role of IBD in the context of total health with special attention to diet, nutritional status, life- style considerations, stressors, adrenal health, evidence of dysbiosis, and general wellness Determine extent of success /failure of medical plan; examine prior medical records; coordinate with gastroenterologist as necessary Determine extent of success /failure of medical plan; examine prior medical records; coordinate with gastroenterologist as necessary Discuss patient goals Discuss patient goals Assess possibility of CAM making an impact on prognosis Assess possibility of CAM making an impact on prognosis Use variety of diagnostic methods to determine possible therapies Use variety of diagnostic methods to determine possible therapies

31 Evaluation Patient goals outlined: Patient goals outlined: patient leads the agenda patient leads the agenda better control of symptoms? better control of symptoms? reduced corticosteroids? reduced corticosteroids? decrease reliance on medication? decrease reliance on medication? improved quality of life? improved quality of life? dietary refinement? dietary refinement? treatment of side effects of other medication? treatment of side effects of other medication? more energy? more energy?

32 Lab Testing Helpful in CAM Dysbiosis testing: stool, saliva, breath, antigen, antibody - l Dysbiosis testing: stool, saliva, breath, antigen, antibody - l Adrenal tests: saliva, urine, serum Adrenal tests: saliva, urine, serum Food allergy and intolerance testing Food allergy and intolerance testing GI function and pathogen panels GI function and pathogen panels Nutritional panels Nutritional panels Inflammation markers: ESR, SRP, Fecal Calprotectin, Intestinal Lysozyme, Anti- alpha chymotrypsin, Stool Leukocytes Inflammation markers: ESR, SRP, Fecal Calprotectin, Intestinal Lysozyme, Anti- alpha chymotrypsin, Stool Leukocytes

33 Integrative Treatment Plan Symptoms No Treatment or Unsuccessful Treatment Successful Integrative Plan Meds More Responsive to Meds Or Fewer Meds Better Health More Control Implement dietary strategy Treat Dysbiosis/microbiota Improve digestion Improve nutritional status Work further on lifestyle Improve adrenal function Address psycho-emotional factors

34 What We Tell Patients We are “exploring” the role complementary therapies can play in your care. This is a process. We are “exploring” the role complementary therapies can play in your care. This is a process. We recommend commencement of the complementary plan without changing the medical plan to best assess how baselines change, with continual re-evaluation. We recommend commencement of the complementary plan without changing the medical plan to best assess how baselines change, with continual re-evaluation. We explain that a dietary strategy will be implemented while simultaneously investigating the role of dysbiosis (disruption of microbiota), adrenal fatigue (suboptimal adrenal function), food allergies and intolerances, functional digestive issues, immune dysregulation, and nutritional insufficiencies may be playing. We will implement treatments as patterns that can be perceived emerge. We explain that a dietary strategy will be implemented while simultaneously investigating the role of dysbiosis (disruption of microbiota), adrenal fatigue (suboptimal adrenal function), food allergies and intolerances, functional digestive issues, immune dysregulation, and nutritional insufficiencies may be playing. We will implement treatments as patterns that can be perceived emerge.

35 What We Tell Patients We describe how as baseline symptoms or markers improve as treatments are implemented, then there is a basis for discussion of possible changes in the medical plan in an environment of proper monitoring (e.g., follow-up endoscopies to assure mucosal healing and cessation of progressive disease). We describe how as baseline symptoms or markers improve as treatments are implemented, then there is a basis for discussion of possible changes in the medical plan in an environment of proper monitoring (e.g., follow-up endoscopies to assure mucosal healing and cessation of progressive disease). We recommend continued and ongoing relationship with conventional gastroenterology to stage progress/regress and utilize medical treatment as required. We recommend continued and ongoing relationship with conventional gastroenterology to stage progress/regress and utilize medical treatment as required.

36 Integrative Case Snapshots

37 43 year old nurse, 2011 Diagnosed 2008 with CD after the stress of nursing school. Under care of gastroenterologist confirming disease well under control on Asacol, Cimzia, Hyoscyamine sulfate, Methotrexate, Vicodin bid. However baseline abdominal cramping constant 2-3/1-10, worse waking. No D, but chronic fatigue, headaches, and depression. Patient miserable and frustrated.. Was seeing an ND (Naturopath) who dispensed many supplements and various diets. SCD had been tried, improperly,and assumed a failure Diagnosed 2008 with CD after the stress of nursing school. Under care of gastroenterologist confirming disease well under control on Asacol, Cimzia, Hyoscyamine sulfate, Methotrexate, Vicodin bid. However baseline abdominal cramping constant 2-3/1-10, worse waking. No D, but chronic fatigue, headaches, and depression. Patient miserable and frustrated.. Was seeing an ND (Naturopath) who dispensed many supplements and various diets. SCD had been tried, improperly,and assumed a failure Blood work revealed nutritional insufficiencies. SCD was re-commenced with support, along with weekly nutritional IV therapy x 2 months +weekly acupuncture. Blood work revealed nutritional insufficiencies. SCD was re-commenced with support, along with weekly nutritional IV therapy x 2 months +weekly acupuncture. Response was excellent, with improvements in baseline symptoms within weeks. Response was excellent, with improvements in baseline symptoms within weeks. In coordination with gastroenterologist, all meds tapered over 6 months. Anti- depressant tapered. In coordination with gastroenterologist, all meds tapered over 6 months. Anti- depressant tapered. There have been no relapses. Patient continues timely follow-up with gastroenterologist. There have been no relapses. Patient continues timely follow-up with gastroenterologist.

38 13 year old boy, 2008 CD unresponsive to Asacol, Entocort, Azathioprine, Anucort, Remicade and others. Only responsiveness was high dose prednisone, which when tapered led to relapse: vomiting, acute diarrhea, abdominal pain. Psychological depression and osteopenia at age 13, no growth for 1 year. CD unresponsive to Asacol, Entocort, Azathioprine, Anucort, Remicade and others. Only responsiveness was high dose prednisone, which when tapered led to relapse: vomiting, acute diarrhea, abdominal pain. Psychological depression and osteopenia at age 13, no growth for 1 year. Immediate response to Specific Carbohydrate Diet. Still my patient 8 years later, maintained only on SCD + LDN + adrenal extract + vitamins and minerals. At time of presentation, tests indicated adrenal fatigue, dysbiotic organisims, intestinal permeability, allergy. Return to standard diet led to relapse. When Humira was considered, dietary strategy was chosen. Immediate response to Specific Carbohydrate Diet. Still my patient 8 years later, maintained only on SCD + LDN + adrenal extract + vitamins and minerals. At time of presentation, tests indicated adrenal fatigue, dysbiotic organisims, intestinal permeability, allergy. Return to standard diet led to relapse. When Humira was considered, dietary strategy was chosen. He experiences rare minor flares, addressed with return to stricter version of diet and rare use of “physiological dosing “ of bio-identical compounded hydrocortisone, nutritional IV therapy. He experiences rare minor flares, addressed with return to stricter version of diet and rare use of “physiological dosing “ of bio-identical compounded hydrocortisone, nutritional IV therapy.

39 13year old boy L W 2008

40 2011 “W”“W”“L”“L” 2011

41 38 year old P.T. student, 2013 UC since age 11 well managed by Mesalamine enemas until high school when she required prednisone frequently until college when Asacol was added. Managed well with Asacol ununtil pregnancy and childbirth in Flared with birth of daughter, and Asacol no longer held remission. At presentation, just finished 40mg Prednisone taper with flare of constant abdominal pain, 8-10 urgent liquid stools/day, still on Asacol and being offered Humira next. Breastfeeding newborn and refusing to go on immunosuppresants. UC since age 11 well managed by Mesalamine enemas until high school when she required prednisone frequently until college when Asacol was added. Managed well with Asacol ununtil pregnancy and childbirth in Flared with birth of daughter, and Asacol no longer held remission. At presentation, just finished 40mg Prednisone taper with flare of constant abdominal pain, 8-10 urgent liquid stools/day, still on Asacol and being offered Humira next. Breastfeeding newborn and refusing to go on immunosuppresants. Treatment work up commenced while implementing SCD trial with full clinical support. One month on diet led to reduction of numbers of stools to 5 per day, and with persisting but decreased urgency, and less pain. Stool and Saliva testing testing yielded Candida Albicans overgrowth and suboptimal adrenal cortisol production. Nystatin prescribed alternatiing with anti-fugal supplements, as well as low dose “physiological dosing” of compounded hydrocortisone, 5mg am, 2.5mg late am, and 2.5 mg late afternoon. Treatment work up commenced while implementing SCD trial with full clinical support. One month on diet led to reduction of numbers of stools to 5 per day, and with persisting but decreased urgency, and less pain. Stool and Saliva testing testing yielded Candida Albicans overgrowth and suboptimal adrenal cortisol production. Nystatin prescribed alternatiing with anti-fugal supplements, as well as low dose “physiological dosing” of compounded hydrocortisone, 5mg am, 2.5mg late am, and 2.5 mg late afternoon. After 2 weeks, patient reports normal stools 1-2 day, good formation, and no abdominal pain. She is asymptomatic and happily breastfeeding. Will have follow-up colonoscopy in 1 month. After 2 weeks, patient reports normal stools 1-2 day, good formation, and no abdominal pain. She is asymptomatic and happily breastfeeding. Will have follow-up colonoscopy in 1 month.

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45 10 year old boy, 2013 Referred by pediatric gastroenterologist for complementary care because family is interested in a dietary strategy for child’s UC after 2012 conventional care failed to hold with Pentasa. Steroids were re- commenced and a variety of dietary options discussed. In counseling patient, a simple “paleolilthic” type diet was started as SCD appeared too limiting and overwhelming. Referred by pediatric gastroenterologist for complementary care because family is interested in a dietary strategy for child’s UC after 2012 conventional care failed to hold with Pentasa. Steroids were re- commenced and a variety of dietary options discussed. In counseling patient, a simple “paleolilthic” type diet was started as SCD appeared too limiting and overwhelming. Diet alone appeared to allow successful taper of prednisone without flaring and very low level of abdominal pain. Remicade infusions q 8 weeks added to plan, but baseline, minor abdominal pain persists. Allergy testing informed further modifications to diet, and along with digestive support from supplementation (enzymes, HCL), pain appears to be decreasing. Diet alone appeared to allow successful taper of prednisone without flaring and very low level of abdominal pain. Remicade infusions q 8 weeks added to plan, but baseline, minor abdominal pain persists. Allergy testing informed further modifications to diet, and along with digestive support from supplementation (enzymes, HCL), pain appears to be decreasing.

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47 27 year old female Found clinic through clinic’s monthly IBD support. CD since age 6, now under fairly good control with Remicade every 8 weeks. However frustrated because she starts to flare at 6 weeks of each cycle with frequency, urgency, and abdominal pain. Mildly elevated CRP. GI doc suggests next step in meds which patient wishes to avoid. Found clinic through clinic’s monthly IBD support. CD since age 6, now under fairly good control with Remicade every 8 weeks. However frustrated because she starts to flare at 6 weeks of each cycle with frequency, urgency, and abdominal pain. Mildly elevated CRP. GI doc suggests next step in meds which patient wishes to avoid. SCD is properly implemented with support and brings improvement to the last two weeks of the cycle, but not enough for patient satisfaction. SCD is properly implemented with support and brings improvement to the last two weeks of the cycle, but not enough for patient satisfaction. Allergy test reveals that she is eating many foods to which she has apparent intolerance and substantial IgG reactions. Allergy test reveals that she is eating many foods to which she has apparent intolerance and substantial IgG reactions. Removal of those foods ameliorates symptoms further to patient satisfaction, with Remicade infusions holding for entire cycle. CRP and other inflammation markers will be followed prior to next colonoscopy. Removal of those foods ameliorates symptoms further to patient satisfaction, with Remicade infusions holding for entire cycle. CRP and other inflammation markers will be followed prior to next colonoscopy. Instruction in mindfulness based stress reduction helps patient further. Instruction in mindfulness based stress reduction helps patient further.

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49 63 year old Fistualizing CD Referred by gastroenterologist for complementary care post total proctocolectomy (1970’s) with stoma inflammation, reoccurrence of fistula, recent MRI showing new areas inflammation in ileum and jejunum, fatigue, elevated CRP. Patient has history of intolerance to Remicade and Humira. Referred by gastroenterologist for complementary care post total proctocolectomy (1970’s) with stoma inflammation, reoccurrence of fistula, recent MRI showing new areas inflammation in ileum and jejunum, fatigue, elevated CRP. Patient has history of intolerance to Remicade and Humira. Work-up yields lack of evidence of dysbiosis, lack of evidence of adrenal fatigue, allergies to only cane sugar, no gross nutritional deficiencies save vitamin D, but elevated fasting blood sugar. Work-up yields lack of evidence of dysbiosis, lack of evidence of adrenal fatigue, allergies to only cane sugar, no gross nutritional deficiencies save vitamin D, but elevated fasting blood sugar. SCD attempted, but too much weight loss and strategy abandoned. Patient agrees to decreased refined carbohydrates and commences Low Dose Naltrexone (LDN), weekly methlycobalamin injections at home, and periodic nutrtional IV support, as well as supplemental Curcumin. SCD attempted, but too much weight loss and strategy abandoned. Patient agrees to decreased refined carbohydrates and commences Low Dose Naltrexone (LDN), weekly methlycobalamin injections at home, and periodic nutrtional IV support, as well as supplemental Curcumin. 3 months later: improved energy, closed fistula, normalized CRP, stoma uninflamed. Excellent example of good, coordinated complementary care. 3 months later: improved energy, closed fistula, normalized CRP, stoma uninflamed. Excellent example of good, coordinated complementary care.

50 What’s Working? Overall integration Overall integration Implementing a dietary strategy Implementing a dietary strategy Microbial balancing Microbial balancing Treating the “whole” of digestion Treating the “whole” of digestion “Energetic” medicine component “Energetic” medicine component Low Dose Naltrexone Therapy Low Dose Naltrexone Therapy Treating nutritional deficiencies & insufficiencies Treating nutritional deficiencies & insufficiencies Combining therapies, observing outcomes SCD, GAPS, AID, Hypoallergenic Anti-microbial meds, herbs, SCD, probiotics, fecal transplant? hypochlorhydria, pancreatic insufficiency, probiotics 1.5mg – 4mg at bedtime Oral supplementation, intravenous nutrition, anti-oxidants, amino acids, trace minerals E.G., Acupuncture

51 What’s Working? Stress Reduction Stress Reduction Detoxification, allergy-load reduction, meditation, exercise, Tai Qi, Qi Gong, prayer, Psychological counseling

52 Integration “Combining parts so that they work together, or form a whole…” Conventional Medical Plan Conventional Medical Plan Complementary Medical Plan Integrative Care Needed Needed Desired Desired Effective Effective Feasible Feasible Probably Cost-efficient Probably Cost-efficient

53 Combining Therapies For Optimal Results Complementary and Integrative Care for Inflammatory Bowel Disease Gary Weiner, N.D., L.Ac. Pearl Natural Health


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