Against the Grain

This is my review of Zeposia (Ozanimod), a new once a day oral medication for moderate to severe ulcerative colitis. I go over the True North Study (https://www.nejm.org/doi/full/10.1056/NEJMoa2033617) in detail including efficacy and safety data. I have no conflicts of interest with any pharmaceutical companies. These are my opinions regarding Zeposia and other medications based on my personal/clinical experience and review of the literature. 

Dr. Shriram Jakate is Professor Emeritus in pathology at Rush University Medical Center. He has a particular expertise in GI and liver pathology and has been interpreting slides from patients with Crohn's and colitis for over several decades. I consider him to be the best GI pathologist I have encountered in my career and during this podcast we have a wide ranging discussion about interpretation of IBD pathology. We discuss the pathologic features of Crohn's and ulcerative in detail and also go over IBD mimickers (including NSAID induced inflammation), C diff, pouchitis and rethinking the classification of IBD subtypes. 

This is a discussion with Dr. Assad Munis, third year gastroenterology fellow at Advocate Lutheran General Hospital, about his recent presentation "Initial Approach to Fistulizing Crohn's Disease" at our grand rounds.  
We discuss pathophysiology, diagnosis, and primarily medical management. We also touch on topics of stem cell therapy, hyperbaric oxygen and exclusive enteral nutrition as potential treatments. 

I made this podcast for those who are newly diagnosed with Crohn's disease or ulcerative colitis.

Dr. K’s Simplified Prescription to Treat IBD

(it’s not that complicated to know what to do)

1.Start with appropriate and optimized medical therapy, preferably by an IBD specialist (like myself).

2.If this works, follow an IBD diet protocol that speaks to you and that you can realistically follow long term. Bottom line is to take out processed food and being plant based is probably helpful.

3.After at least 1 year, if in deep remission (feeling normal, normal colonoscopy, normal biopsies), continue meds if no side effects or consider de-escalation of medical therapy (ie stopping or reducing dose) and continue diet with careful monitoring strategy for recurrence. If there is disease recurrence, restart medical therapy at direction of IBD specialist and consider changing dietary protocol.

4.If you run out of medical therapies or are stuck on prednisone, surgery is a good option which can not only save your life but improve your quality of life.

5.Besides diet and medication, other complementary and alternative therapies (ie supplements, probiotics, etc) are unlikely to be the miracle you hope for.

That is all!

To schedule a phone conversation with me, go to:
https://calendly.com/samir3/against-the-grain

This podcast is a deep dive into the recently published article "A Randomized Trial Comparing the Specific Carbohydrate Diet to a Mediterranean Diet in Adults With Crohn’s Disease." 
(also known as the Dine Study) published by Lewis, et al. 
Article link is here: https://pubmed.ncbi.nlm.nih.gov/34052278/

My guests are Dr. Meghana Doniparthi, gastroenterology fellow at Advocate Lutheran General Hospital and 
Kim Beall, Pharm D.
Kim received her Doctor of Pharmacy from the Medical University of South Carolina (MUSC) and her BS in Pharmacy from Auburn University. She has experience in academics and industry, working at MUSC as part of an Internal Medicine team and serving as adjunct faculty at MUSC College of Pharmacy, then working in Health Sciences with Merck as an academic liaison for those publishing and researching in lipids, hypertension, and heart failure. She has been following research in IBD closely since 2013 with her teenage son’s diagnosis of Crohn’s disease, and has become committed to the advancement of nutritional therapy as treatment. 
Her website is http://www.ntforibd.org

This is my second podcast with IBDCoach. We try to make sense of all the IBD diets, supplements and medications out there which can be so confusing! We also have a detailed discussion regarding Andrew's use of Ksharsutra (Ayurvedic Seton) to treat his fistula. 

I am not officially endorsing or recommending this service or Ksharsutra. You must discuss using any adjunctive therapies with your gastroenterologist.

Andrew Kornfeld ([email protected]) holds degrees in Neuroscience and Psychology from UC Santa Cruz and is an award-winning educator, organizer, and published author. He has Crohn’s disease, and over the course of a decade and a half has developed a tailored and evidence-based protocol that allowed him to achieve robust, lasting clinical remission from his IBD. Andrew founded IBDCoach (www.ibd.coach) so others with Crohn’s disease and ulcerative colitis could benefit from the strategic lessons and research he has conducted in his personal pursuit of health.

Amy Loftus ([email protected]) holds a B.A. in Biological Anthropology and an M.A. in Education from the University of California, Berkeley. She works alongside Andrew to run the operations arm of IBDCoach. Amy combines her decade of classroom teaching experience, her work as a software engineer at a Silicon Valley health tech startup, and her years as an IBD spouse to empower IBDCoach members with the resources they need to achieve their remission goals.

There are many reasons why a whole food plant based diet may be helpful for Crohn’s disease and ulcerative colitis. Data suggest limiting omega-6 PUFAs (ie oils), saturated fats, animal protein, and food additives may be associated with a reduced risk of developing IBD. A whole food plant based diet seems to check all of those boxes. However, this doesn’t change the fact that there are some out there who respond to the Specific Carbohydrate Diet (which is a monosaccharide diet) that does not restrict meat, cheese or cooking oils. Enthusiasm for a whole food plant based diet is gaining steam not just for IBD but also other health conditions like heart disease, obesity, diabetes and prevention of cancer. It’s important to remember that there still is a lot of controversy regarding what is the optimal diet for human health if such a thing exists. Today I interviewed Shamiz and Shukul Kachwalla who are brothers who run High Carb Health and promote a whole food plant based diet. Shamiz has ulcerative colitis and has been maintaining drug free remission with a whole food plant based diet for over seven years. As a disclaimer, this podcast should not be interpreted as medical advice and is not an official endorsement of this diet for the treatment of inflammatory bowel disease especially without appropriate medical therapy.

Their website: https://www.highcarbhealth.com/

Crohn's Disease Remission with a Plant-Based Diet: A Case Report:
https://pubmed.ncbi.nlm.nih.gov/31226766/

Lifestyle-related disease in Crohn's disease: relapse prevention by a semi-vegetarian diet
https://pubmed.ncbi.nlm.nih.gov/20503448/

For all the mega Against the Grain fans out there, here is the full theme song, version #1 in all its glory. The part you are familiar with is in the middle of the track.

Produced and Written by Samir Kakodkar. Borrowed some parts from theme from the ABC reality TV show The Mole (that nobody watched).
Circa 2003 at Northwestern University, Foster Walker Complex, on a microKorg and Garage Band.

For all the mega Against the Grain fans out there, here is the full theme song, version #2 in all its glory.

Produced and Written by Samir Kakodkar
Circa 2003 at Northwestern University, Foster Walker Complex, on a microKorg and Garage Band.

There are many theories out there regarding what causes Crohn’s disease. Though ultimately most physicians and scientists acknowledge that we don’t know the cause, there is a small subgroup that believe Crohn’s disease is caused by a specific bacteria called mycobacterium avium paratuberculosis which we will abbreviate as MAP. MAP mainly comes from infected cattle but is now ubiquitous in our environment and all of us are likely exposed to it on a regular basis.
The treatment paradigm for Crohn’s has mainly been the use of immunosuppressive medications which target a dysregulated immune system thought to be central to the pathophysiology of the disease. However, there are some that treat Crohn’s by targeting MAP with the use of antibiotics, fecal transplants and hyperbaric oxygen. There is even an anti-MAP vaccine in development. In my opinion, this is the biggest controversy in the IBD field right now. In fact, the Crohn’s Disease guidelines published by the American College of Gastroenterology in 2018 explicitly state that anti-MAP therapy has not been shown to be effective for induction or maintenance of remission or mucosal healing in patients with Crohn’s disease and should not be used as primary therapy. This led to subsequent letters being published in the American Journal of Gastroenterology both criticising and defending this statement.

Today I interviewed gastroenterologist Gaurav Agrawal and microbiologist John Aitken who are MAP experts and will give us a comprehensive overview of this topic.
As a disclaimer, I am not formally endorsing this therapy for Crohn’s disease as it has not been FDA approved for this purpose in the US. This podcast should not be interpreted as medical advice. This is an open discussion in order to encourage more research and awareness of this topic.

ACG Clinical Guideline: Management of Crohn’s Disease in Adults:
https://pubmed.ncbi.nlm.nih.gov/29610508/

Comment on 2018 ACG Clinical Guideline: Antibiotics in Crohn's Disease:
https://pubmed.ncbi.nlm.nih.gov/30333546/

Response to Chamberlin and Borody
https://pubmed.ncbi.nlm.nih.gov/30633034/

Two-year Combination Antibiotic Therapy With Clarithromycin, Rifabutin, and Clofazimine for Crohn's Disease:
https://pubmed.ncbi.nlm.nih.gov/17570206/

Targeted Combination Antibiotic Therapy Induces Remission in Treatment-Naïve Crohn's Disease: A Case Series:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7142403/

Combining infliximab, anti-MAP and hyperbaric oxygen therapy for resistant fistulizing Crohn's disease
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5137971/

Profound Remission in Crohn's Disease Requiring No Further Treatment for 3-23 Years: A Case Series
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144342/

Website regarding Crohn’s Disease Vaccine:
http://www.crohnsmapvaccine.com

John Aitken’s
Website:
https://otakaropathways.co.nz/about.php

Email:
[email protected]