Many patients with Crohn’s disease ask what they should do about the medication they are taking when they start dietary therapy. Should they stop it straight away? Or should they reduce the dose?
The best advice is to continue on the current drug therapy until symptoms have settled on diet. Most people switch from medication to diet because their pills are not controlling the disease and they therefore still have unpleasant symptoms. Indeed, if a patient is completely well on his medication, there is usually no need to change it. At present no instant cure for Crohn’s is available. The aim must be to relieve symptoms completely so that the patient can lead a normal life, and to keep them controlled until the disease burns itself out, which may take several years. If tablets are doing the trick, why change a winning team?
Most people therefore will start diet because they are still suffering symptoms despite their medication. Under these circumstances it is usually easy to spot the improvement which diet produces. When the symptoms are nicely controlled, then is the time to start reducing the dose in the expectation that it will be possible to stop the tablets completely after a few weeks.
Indeed, it is sometimes dangerous to stop medication and start diet at the same time. This is because diet works by denying the intestinal bacteria the nutrients on which they depend. In consequence, many millions die in the first few days of starting diet, and at this time many patients notice unpleasant symptoms such as headache, joint and muscle pains and fatigue. Indeed such symptoms are a reassurance that the diet is truly proving effective. These symptoms are produced by the release of toxic chemicals from the dying bacteria, and there may be a temporary worsening in the symptoms of the disease. When bacterial die-off ceases, these symptoms all rapidly clear. If, however, medication is withdrawn at the same time as die-off is occurring, a nasty flare of Crohn’s disease may occur.
Thus it is important not to stop the medication until symptoms are clearly improving. In practice we usually leave people on their medication, provided, of course, that it is not producing nasty side-effects, until their diet is finally established. The process of food testing is not hampered by drugs such as 5-ASA compounds, azathioprine, budesonide, infliximab or Humira, and these can be continued as foods are re-introduced. Problems sometimes arise with prednisolone in high doses as this has many other effects as well as immuno-suppression and food reactions may be disguised if patients are taking more than 10mg prednisolone daily, or the equivalent dose of other systemically absorbed corticosteroids. In this case it is best to reduce the dose (usually by 5mg/day each week) after symptoms are controlled until it reaches 10mg or less, when food re-introduction may begin.
When patients are taking two or more different medications for their Crohn’s, it is best for them to seek advice from their clinicians about which to withdraw first, but corticosteroids are usually the first to go because of their wide side-effect profile.
In a very few patients with difficult Crohn’s disease it is necessary to use both diet and medication together to keep the disease under complete control. This is not a reason for anxiety – the aim is to relieve symptoms until the condition has burned itself out, and using diet and drugs together may provide a very satisfactory solution.
This article was first published on the original crohns.org.uk blog. Research has moved on since, so please check current advice with your IBD team.