Meet the Researchers Who Are Working to Change the Future of UC
There is a lot of exciting science happening right now, all with the goal of bringing new and ever more effective treatments to people with ulcerative colitis. We chatted with some of the top docs in the field to bring you the latest.
Editor's Note: This story is part of a new series on HealthCentral called "Get Your Ph.D.!", which is geared toward people who've got the basics of their condition down and want to up their expertise. Who's ready to go pro?!
It’s never a good time to be living with a chronic illness like ulcerative colitis (UC), but compared with even just a decade or two ago, folks with UC today have a lot more going for them in the way of hope.
There are many reasons for that hope—a huge one being the increase in treatment options available for UC, a form of inflammatory bowel disease (IBD). And there are even more promising developments coming down the pike, thanks to researchers working hard to improve UC care at every step of the process: all the way from diagnosis to hopeful remission. Even if you feel like you’ve been living with UC so long you could qualify as a bonafide expert, we guarantee there’s still plenty to learn.
We spoke with some top experts in the field of IBD to get the scoop on the hottest research topics right now, including precision medicine for UC, the role of the gut microbiome in UC patients, and using cannabis as a complementary therapy. Get ready to nerd out over the latest in UC research. (Spoiler alert: It’s exciting stuff!)
The Future of UC: Precision Medicine
MEET THE EXPERTS:
Caren Heller, M.D.
Chief scientific officer at the Crohn’s and Colitis Foundation (CCF) in New York City
Andres Hurtado-Lorenzo, Ph.D.
Senior director of translational research at the Crohn’s and Colitis Foundation in New York City
Precision medicine—it’s a buzzword in the world of health. And yep, that means the top UC researchers are homing in on this topic, too. In fact, many believe it’s the way forward for UC treatment. Basically, precision medicine is an approach that focuses on getting you the treatment that’s right for you, tailored to your needs—at the right time. What’s not to love, right?
First, some background: Why is precision medicine an important focus area for UC research? “Crohn’s disease and UC are deeply complex diseases with a range of factors influencing patients’ symptoms, disease course, and response to treatments,” explains Dr. Heller. “No two patients have the same experience; what works for one, might not work for another. There is no one-size-fits all approach. That’s why accelerating research toward precision medicine is a priority.”
In fact, the CCF thinks this research area is so important that they’ve launched two huge efforts to help accelerate the process: IBD Plexus, a huge patient database available to researchers, and IBD Ventures, which allows the foundation to invest in products being developed by biotech companies and academics so new treatments, devices, and diagnostic tools for IBD can get to doctors and patients faster. One example of this? They're currently working with a company that’s developing a blood-based gene-expression test for people diagnosed with IBD. Basically, the test could predict whether you have a high or low risk of having a more aggressive course of your IBD right when you’re diagnosed, explains Dr. Heller.
“This test will allow clinicians to make early and personalized treatment decisions according the patient’s predicted disease course—and would avoid the trial and error of the current standard of care, leading to improved disease outcomes.”
Precision medicine could change the way your UC is treated in the coming years. Here are three main takeaways:
The main goal right now is to identify new biomarkers. But what the heck is a biomarker, you may wonder? It’s simply a way to measure different aspects of disease. "That can be any number of things, from blood-pressure readings to cholesterol levels or a chest x-ray,” explains Hurtado-Lorenzo. One current UC biomarker is the “histology score” on a biopsy of your colon; that’s the number you’re assigned based on the severity of your condition. Other biomarkers might be the presence of antibodies in the blood, for example.
Being able to measure different types of biomarkers could help your UC get better much faster. That’s because they can help doctors better predict certain things about your disease, like which medication might work best for you. “Using an analogy, it’s like when you have an infection, and the doctor guesses at the right antibiotic for you to take, compared to when the doctor gets a culture and knows which bacterium actually is causing your infection. That information means prescribing the exact medicine you need, enabling you to get better, quicker,” explains Hurtado-Lorenzo. “We’re also looking for biomarkers that give us that level of understanding about which drug to choose.” In fact, a test to predict how well you might respond to treatment with biologics could be available in the United States in the next five to 10 years, he says—pretty awesome!
Biomarkers might also reveal new drug targets. “Ongoing research to help identify specific genes and proteins that are altered or don’t function as they should in patients with UC will open the avenue for the development of new, more personalized, therapies, too,” he says. If researchers can figure out how to restore function to these faulty genes and proteins, the body may be able to heal itself.
The Microbiome and UC: Getting to the Gut of the Matter
MEET THE EXPERT:
Charles N. Bernstein, M.D.
Distinguished professor of medicine at the University of Manitoba in Winnepeg, Canada and director of the university's IBD Clinical and Research Centre
If you’re at all interested in IBD research, you’ve likely come across the term “gut microbiome” before. As it turns out, the gut microbiome may hold the keys to many UC mysteries, according to researchers.
What exactly is the gut microbiome? In short: “It’s all of the bugs residing in the bowel,” says Dr. Bernstein, who co-authored a 2019 study on the topic published in Current Treatment Options in Gastroenterology. That includes trillions of microorganisms, bacteria, viruses, protozoa, and fungi that make their living in your digestive tract. While the idea of the microscopic creepy crawlies—officially known as microbiota—hanging around in your body sounds a little gross, it’s usually a perfectly healthy situation. But when the balance of the microbiome is off, your health may be affected—and yep, that includes your UC.
“The bugs residing in our bowel are important for maintenance of health. It is thought that diseases like IBD occur because of some disruption to the gut microbiome—either too many of bad bugs or too few of good bugs,” explains Dr. Bernstein.
Here’s what you need to know about the latest research on the gut microbiome and what’s in the pipeline for UC treatment.
Research show that the gut microbiome in UC patients is out of whack. “The term for this is dysbiosis, meaning that it is different than what is expected normally,” says Dr. Bernstein. And yes, it is possible that the gut microbiome imbalance is involved in the development of UC in the first place. It’s not yet known how, exactly, but one possibility is that the imbalance triggers an abnormal immune response that leads to UC, he says.
Altering the gut microbiome may help treat UC one day. If it’s possible that an imbalance of microscopic critters in your gut could lead to UC in the first place, does it hold that fixing that imbalance could correct the problem? It’s possible, says Dr. Bernstein. “That is the hope—that we can determine where the gut microbiome is deficient and how to replace the right bugs to correct it.” And no, that’s not as simple as heading to the drug store right now and popping some probiotics, unfortunately. In fact, the current research shows that there’s no role for probiotics in people with IBD right now because existing options aren’t effective in clinical trials, says Dr. Bernstein—likely because the they just don’t contain the right microbes. "However, once there is more information on which bugs may be deficient in people with IBD, perhaps a ‘super-probiotic’ can be developed.”
Research on the gut microbiome and UC treatment is very much a work in progress. “Different research groups are attempting to identify the specific abnormalities in UC patients’ gut microbiomes, and how they can be rectified with manipulation of the gut microbiome.” Zeroing in on the specific bugs people with UC need more of is the main goal—then work on that super probiotic can start.
What we do know now, according to Dr. Bernstein’s study, is that it’s likely that any treatment for IBD involving modification of the gut microbiome would call for a highly individualized approach for each patient (that's where personalized medicine comes in) and be combined with other IBD therapies.
While we have a ways to go before we have a mainstream treatment for UC focusing on the gut microbiome, it’s a topic researchers and IBD experts are excited about. It’s even the focus of a research initiative at the Crohn’s and Colitis Foundation, who believe identifying and analyzing the microbial agents in the gut may help uncover the causes of IBD and help bolster the search for—yes, that elusive word—a cure. Watch this space.
Cannabis and UC: A Healthy Match?
MEET THE EXPERT:
Jami Kinnucan, M.D.
Gastroenterologist at Michigan Medicine, University of Michigan in Ann Arbor
It’s incredibly common for people living with a chronic illness like UC to seek out complementary therapies when their traditional medical therapies alone just aren’t cutting it—in fact, 38% of adults have used a form of complementary or alternative medicine, per the National Institutes of Health. Important distinction here: Complementary therapies are used in conjunction with your current medical therapies—they don’t replace them entirely. They can include things like dietary supplements, herbs, probiotics, and more.
Perhaps the hottest complementary therapy around in the past few years? Cannabis. Yep—weed, pot, whatever you want to call it. Here, we’re focusing on two key compounds of cannabis: tetrahydrocannabinol (THC), which is the compound that gets you high, among other things; and cannabidiol (CBD), which is popping up more and more in products as a trendy way to potentially relieve pain and ease anxiety. But can it help your UC?
To get the facts, we spoke with Dr. Kinnucan, whose research interests include cannabis use in IBD patients. It’s actually really, really hard to research cannabis in the United States. “Cannabis remains federally illegal, which makes it more challenging to study cannabis in a meaningful way, including the absence of prospective randomized controlled trials conducted in the United States,” explains Dr. Kinnucan. That means that all the real studies we have so far are coming out of Israel and other places outside of this country. It’s not that doctors in the U.S. can’t rely on these trials, but it’s always preferable to conduct original research on the actual population you’d be treating.
Hopefully in the coming years, more and more data will pour in to help us understand the potential effects of cannabis on UC. For now, here are the biggest takeaways so have so far.
Some people with UC want to use cannabis to treat their inflammation, but there’s a problem with that. While it’s been theorized that cannabis could possibly improve the underlying disease, we have some bad news: The two studies that have been done to date on UC and cannabis (including one on THC and one on a combination of CBD and THC) found no evidence that cannabis significantly improves disease activity, says Dr. Kinnucan. There were only about 100 patients total across all three trials, so these studies were small—but still, no solid evidence is no solid evidence. Dr. Kinnucan says if patients are using cannabis to treat their actual UC inflammation, we have no convincing data that it works for that.
But cannabis could help your UC symptoms. “We do have information from these studies that UC patients do have improvements in symptoms,” says Dr. Kinnucan. There is a catch, though: The data on this is a tad more convincing for people with Crohn’s rather than UC, and overall, the studies are very small. Despite that, she says, we do know that people with UC who use cannabis can have a temporary decrease in gastric motility, diarrhea, and pain symptoms. “And because it can decrease nausea and abdominal symptoms, it can actually increase appetite and be an appetite stimulant too,” she adds. So some people may experience relief from certain symptoms while using cannabis, but those symptoms often return once use stops.
And last but not least, Dr. Kinnucan says several of her UC patients use cannabis mainly for potential sleep improvement: “There have been studies that show that patients who use cannabis do have improved sleep quality—that’s in both the general public and some of the smaller IBD studies. However, some sleep experts have concerns about cannabis withdrawal—increasing need for cannabis over time to be able to achieve the same level of sleep, and then chronic use can actually lead to sleep disturbance that patients aren’t aware of where they aren’t actually getting enough quality sleep.”
There could be dangers to using medical cannabis for UC. The main thing docs are worried about is that people who start using cannabis to help with their UC will stop using their doctor-prescribed medications, says Dr. Kinnucan. "It’s been shown that patients who use cannabis are significantly more likely to stop their traditional medical therapies for their IBD. These patients use cannabis alongside their medical therapy, and they feel better—but then they stop their traditional UC medical therapy.” And we know that discontinuation of medical therapy increases the risk for disease relapse or disease progression, she says.
Please, please, please, don’t stop your medications without talking to your doctor first. It’s also important to consider other risks of cannabis that we may not fully understand yet. For example, some data shows that cannabis use might contribute to the development of fibrosis in the bowel and liver in IBD patients, and one large retrospective Canadian study found that people who use it were more likely to have surgery for their IBD than those who didn’t use it, says Dr. Kinnucan. While it’s not clear whether there’s a direct link there, it’s something to keep in mind.
So yeah... you should really talk to your doctor before you try cannabis for your UC on your own. "When I have a patient with UC who comes to me wants to start using cannabis, I first ask about the symptoms they’re trying to treat. If they say they’re not really having symptoms but just want to see if cannabis can treat their disease, we talk about the lack of evidence to support that approach,” says Dr. Kinnucan. If they say they want to use it for controlling certain symptoms, she’ll talk with them about why they might be having those symptoms and the best way to address them before giving the greenlight for cannabis—there could be other therapies that are more appropriate for those particular issues. For example, if a patient has ongoing symptoms of diarrhea or urgency, Dr. Kinnucan says, the doctor should evaluate for active disease as a possible cause. Treatment should focus on that active disease if it is present.
And don’t forget—cannabis use may not even be legal in your state, medically or recreationally or both. You can check the latest on your state’s laws on the National Conference of State Legislature’s website.
If you are going to try cannabis for your UC symptoms (ideally after getting your provider’s blessing), there are even more considerations that we just don’t have enough data on yet to give firm recommendations on, says Dr. Kinnucan. “I can’t actually advise patients on dosing due to the lack of guidance from current studies in IBD; the doses and the route of administration vary from one study to the other,” she explains. “Some studies looked at oral formulations, some studies looked at the inhalation route, some studies are looking at just THC formulation, and some studies are looking at CBD with various percentages of THC—so I can’t even advise them on what exactly they should be using. If patients are interested in incorporating cannabis, I advise them to start with the lowest dose of CBD/THC and titrate as needed. Oral administration is preferred over inhalation given the risks associated inhalation.”
The big take-home message here, says Dr. Kinnucan, is to talk to your health care provider about how cannabis could impact you—positively and negatively—before diving in, and know that there’s no data to support that cannabis can treat your UC inflammation, even if it may help with some of your symptoms. Lastly, it bears repeating, but don’t stop your traditional medical treatments, even if you feel better after starting to use cannabis.
Crohn’s and Colitis Foundation Research Initiatives: Current Research Initiatives. (2019). Crohn’s and Colitis Foundation. crohnscolitisfoundation.org/research/current-research-initiatives
Data on Complementary and Alternative Therapies: The Use of Complementary and Alternative Medicine in the United States. (2017). National Center for Complementary and Integrated Health, National Institutes of Health. nccih.nih.gov/research/statistics/2007/camsurvey_fs1.htm
Gut Microbiome and IBD Study: Current Treatment Options in Gastroenterology. (2019). “The Gut Microbiome as a Target for IBD Treatment: Are We There Yet?” link.springer.com/article/10.1007%2Fs11938-019-00221-w
Information on Medical Cannabis and UC: Medical Cannabis. (2019). The Crohn’s and Colitis Foundation. crohnscolitisfoundation.org/science-and-professionals/education-resources/whitepapers/medical-cannabis
Study on Cannabis and Fibrosis: Canadian Association of Gastroenterology. (2018) “Canadian Association of Gastroenterology Position Statement: Use of Cannabis in Gastroenterological and Hepatic Disorders.” academic.oup.com/jcag/article/2/1/37/5166404
Study on Cannabis and IBD: Digestion. (2012). “Impact of Cannabis Treatment on the Quality of Life, Weight and Clinical Disease Activity in Inflammatory Bowel Disease Patients: A Pilot Prospective Study.” ncbi.nlm.nih.gov/pubmed/22095142
Study on Cannabis and UC Improvement: Journal of Crohn's and Colitis. “P398 Cannabis induces clinical and endoscopic improvement in moderately active ulcerative colitis (UC).” academic.oup.com/ecco-jcc/article/12/supplement_1/S306/4808102
Study on CBD and UC: Inflammatory Bowel Diseases. (2018). “A Randomized, Double-blind, Placebo-controlled, Parallel-group, Pilot Study of Cannabidiol-rich Botanical Extract in the Symptomatic Treatment of Ulcerative Colitis." academic.oup.com/ibdjournal/article-abstract/24/4/714/4925788?redirectedFrom=fulltext