Crohns Disease and Fibromyalgia
Crohn’s disease is a condition marked by severe inflammation of the intestines. Specific areas of inflammation vary among affected individuals. For example, some people only experience inflammation in their small intestine, whereas others experience it only in the colon (a portion of the large intestine). However, the most commonly affected areas among all individuals with Crohn’s disease include the ileum (the end part of the small intestine) and the colon. When inflammation is limited only to the intestinal wall, it can result in scarring and stenosis (blockage) of the intestines. When it spreads through the bowel wall, it can result in what is known as a fistula, or abnormal connection between two body parts.
No one knows exactly what causes Crohn’s disease. Although diet and stress have been known to aggravate the condition, they do not cause it to develop. Some researchers believe that a virus or bacteria may lead to the development of Crohn’s disease, by triggering the body’s immune system to abnormally attack the digestive tract. In addition, individuals with a family history of Crohn’s disease are more likely to develop it than those who have no family history, which suggests that genetic influences may also play a role.
In terms of risk factors, a few common factors have been identified in addition to family history. Most individuals with Crohn’s disease are diagnosed before the age of 30, although it can occur at any age. Race and ethnicity are also risk factors. Whites have the highest risk of developing Crohn’s disease; however, white individuals of eastern European descent (in particular Ashkenazi Jewish descent) have the greatest risk. In addition, cigarette smoking also increases the risk of developing Crohn’s disease and is the most controllable risk factor. Individuals who smoke not only run a higher risk of developing Crohn’s disease but they also tend to have more severe symptoms. Finally, individuals who live in urban areas or in industrialized countries, as well as those in northern climates, are more likely to develop Crohn’s disease.
Just like its presentation, the symptoms of Crohn’s disease vary among individuals and may occur suddenly or gradually over time. Individuals with Crohn’s disease may also go into remission, which is a period of no symptoms at all. However, when Crohn’s disease is active, the most common symptoms include diarrhea, abdominal pain and cramping, blood in the stool, ulcers, decreased appetite, and weight loss. Other, less common symptoms include fever, fatigue, arthritis, inflammation of the eyes, mouth sores, skin disorders, liver, and bile duct inflammation, and delayed grown or sexual development (in children)
A number of complications can arise from Crohn’s disease. Since it affects the thickness of the intestinal walls, it can cause parts of the intestines to thicken and narrow, which may result in blockage of the flow through the intestines. This can require surgery to remove the diseased intestine. In addition, open sores (ulcers) can develop in the mouth, anus, genital area, and digestive tract. Fistulas can also occur, creating abnormal connections between the intestines and skin, or the intestines and other organs, such as the bladder and vagina. They can cause food to bypass crucial areas of the digestive system as it travels through the bowel, which can lead to decreased nutrient absorption. Fistulas can also become infected and form a life-threatening abscess. In addition, Crohn’s disease increase can result in decreased appetite and weight loss, which can lead to malnutrition and anemia. Crohn’s disease also increases the risk of colon cancer, arthritis, kidney and gall stones, and osteoporosis.
The diagnosis of Crohn’s disease is usually one of exclusion and made only after the possibility of irritable bowel syndrome, diverticulitis (painful inflammation of small folds and pounces lining the intestines), and colon cancer has been ruled out. Testing will usually involve blood tests to check for anemia, testing a stool sample to look for the presence of blood, colonoscopy (viewing the entire colon with a thin, flexible, lighted tube attached to a tiny camera), computerized tomography scan (CT scan; a non-invasive, detailed x-ray procedure used to take pictures of areas inside the body), magnetic resonance imaging (MRI; a non-invasive imaging test that uses radio waves and magnetic fields to take detailed pictures of areas inside the body), and other possible procedures.
Unfortunately, there is no cure for Crohn’s disease and no universally-effective treatment option for all individuals. Overall, the goal of treatment for Crohn’s disease is to reduce the inflammation that leads to its symptoms. This can be done with certain anti-inflammatory drugs, including sulfasalazine (Azulfidine), mesalamine (Asacol, Rowasa), and corticosteroids. Sulfasalazine is most effective for individuals whose Crohn’s disease affects the colon, whereas mesalamine causes fewer side effects but is usually ineffective for individuals who have the disease in the small intestine. Although corticosteroids are effective at reducing inflammation, they have numerous side effects, including generalized swelling, excessive facial hair, night sweats, insomnia, and hyperactivity. They are also not recommended for long-term use.
In addition to anti-inflammatory medication, immune system suppressors can help to reduce inflammation by targeting the immune system response itself. Anti-immune drugs frequently used for Crohn’s disease include azathioprine (Imuran) and mercaptopurine (Purinethol). In addition, adults and children with severe Crohn’s disease may benefit from treatment with infliximab (Remicade). Other possible therapies include adalimumab (Humira), certolizumab pegol (Cimzia), cyclosporine (Gengraf, Neoral), and natalizumab (Tysabri). It is important to note, however, that immune suppression drugs may increase the risk of developing certain cancers, including lymphoma.
Other drugs that may be of benefit to individuals with Crohn’s disease include antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro), as well as over-the-counter medications including antidiarrheals, laxatives, and pain relievers. Vitamin supplements, such as vitamin B-12, calcium, and vitamin D may also be necessary for the treatment of anemia and malnourishment. Finally, diets low in dairy, fat, and fiber (for some people) can help lessen symptoms of Crohn’s disease. Stress and smoking should also be avoided.
A number of natural therapies have been investigated for their use in treating Crohn’s disease. Glutamine and lactobacillus have been studied, but neither has been shown to be helpful at improving symptoms (Den Hond et al., 1999; Akobeng et al., 2000; Zoli et al., 1995). Preliminary evidence suggests that chitosan, fish oil, fluoride, Indian frankincense, and saccharomyces boulardii might help to improve various symptoms of Crohn’s disease, but findings are inconsistent is more research is needed.
The research related to fibromyalgia and Crohn’s disease is limited. A 2001 study by Palm et al. assessed the prevalence of fibromyalgia and chronic, widespread pain among patients with inflammatory bowel disease. Inflammatory bowel disease (IBD) is a general term used to collectively describe the separate conditions of Crohn’s disease and ulcerative colitis. In this study, the researchers evaluated 521 Norwegian patients with a confirmed diagnosis of either ulcerative colitis (353) or Crohn’s disease (168), in order to determine the prevalence of fibromyalgia. They found that 3.5% (18) of all patients combined met the American College of Rheumatology (ACR) criteria for a diagnosis of fibromyalgia. Prevalence rates were similar between the two conditions, with 13 (3.7%) ulcerative colitis patients meeting the criteria for a fibromyalgia diagnosis, compared to five (3.0%) of the Crohn’s disease patients (Palm et al., 2001).
These prevalence rates contrast sharply with those published in a 1999 paper by Buskila et al. In that study, researchers examined 72 patients with ulcerative colitis and 41 patients with Crohn’s disease to determine the prevalence of fibromyalgia, as well as to assess pain thresholds in both groups of patients. Of the 41 patients with Crohn’s disease in this study, 49% met the ACR criteria for a diagnosis of fibromyalgia, versus 30% of the patients with ulcerative colitis. In addition, patients with Crohn’s disease reported increased tenderness and more severe and frequent fibromyalgia symptoms. They also had higher tender point counts. In contrast to the findings of Palm et al., the results of this study suggest a high prevalence of fibromyalgia among patients with Crohn’s disease.
In light of the small number of research studies that have examined the relationship between Crohn’s disease and fibromyalgia, as well as the limitations of existing studies (e.g., small sample sizes), further research is needed in order to better understand the relationship between Crohn’s disease and fibromyalgia.
COVID-19 will likely be with us forever. Here’s how we’ll live with it.
As COVID-19 continues to run its course, the likeliest long-term outcome is that the virus SARS-CoV-2 becomes endemic in large swaths of the world, constantly circulating among the human population but causing fewer cases of severe disease. Eventually—years or even decades in the future—COVID-19 could transition into a mild childhood illness, like the four endemic human coronaviruses that contribute to the common cold.
“My guess is, enough people will get it and enough people will get the vaccine to reduce person-to-person transmission,” says Paul Duplex, director of the University of Pittsburgh’s Center for Vaccine Research. “There will be pockets of people who won’t take [the vaccines], there will be localized outbreaks, but it will become one of the ‘regular’ coronaviruses.”
But this transition won’t happen overnight. Experts say that SARS-CoV-2’s exact post-pandemic trajectory will depend on three major factors: how long humans retain immunity to the virus, how quickly the virus evolves, and how widely older populations become immune during the pandemic itself.
Depending on how these three factors shake out, the world could be facing several years of a halting post-pandemic transition—one marked by continued viral evolution, localized outbreaks, and possibly multiple rounds of updated vaccinations.
“People have got to realize, this is not going to go away,” says Roy Anderson, an infectious disease epidemiologist at Imperial College London. “We’re going to be able to manage it because of modern medicine and vaccines, but it’s not something that will just vanish out of the window.”
The long road to another common cold
One of the essential factors governing the future of COVID-19 is our immunity to the illness. Immunity to any pathogen, including SARS-CoV-2, isn’t binary like a light switch. Instead, it’s more like a dimmer switch: The human immune system can confer varying degrees of partial protection from a pathogen, which can stave off severe illness without necessarily preventing infection or transmission.
In general, the partial protection effect is one of the reasons why the four known endemic human coronaviruses—the ones that cause a common cold—have such mild symptoms. A 2013 study in BMC Infectious Diseases shows that on average, humans are first exposed to all four of these coronaviruses between the ages of three and five-part of the first wave of infections that young children experience.
These initial infections lay the foundation for the body’s future immune response. As new variants of the endemic coronaviruses naturally evolve, the immune system has a head start in fighting them off—not enough to eradicate the virus instantly, but enough to ensure that symptoms don’t progress much beyond the sniffles.
“The virus is also its own enemy. Every time it infects you, it tops up your immunity,” says Marc Veldhoen, an immunologist at the Portugal’s University of Lisbon.
Past studies make clear that partial immunity can keep people from getting seriously ill, even as coronaviruses successfully enter their systems. Long-term, the same is likely to be true for the new coronavirus. Emory University postdoctoral fellow Jennie Lavine modeled SARS-CoV-2’s post-pandemic trajectory based on the 2013 study’s data, and her results—published in Science on January 12—suggest that if SARS-CoV-2 behaves like other coronaviruses, it will likely morph into mild nuisance years to decades from now.
This transition from pandemic to minor ailment, however, depends on how the immune response to SARS-CoV-2 holds up over time. Researchers are actively examining the body’s “immunological memory” of the virus. A study published in Science on January 6 tracked the immune response of 188 COVID-19 patients for five to eight months post-infection, and while individuals are varied, about 95 percent of patients had measurable levels of immunity.
“Immunity is waning, but certainly not gone, and I think this is key,” says Lavine, who wasn’t involved with the study.
In fact, it’s even possible that one of the cold-causing coronaviruses sparked a serious outbreak in the 1800s before fading into the litany of mild, commonplace human pathogens. Based on the spread of its family tree, researchers estimated in 2005 that the endemic coronavirus OC43 entered humans sometime in the late 19th century, likely the early 1890s. The timing has led some researchers to speculate that the original version of OC43 may have caused the “Russian flu” pandemic of 1890, which was noted for its unusually high rate of neurological symptoms—a noted effect of COVID-19.
“There’s no hard proof, but there are a lot of indications that this wasn’t an influenza pandemic but a corona-pandemic,” Veldhoen says.
The crucible of evolution
Though the carnage of past coronaviruses has faded over time, the road to a relatively painless coexistence between humans and SARS-CoV-2 will likely be bumpy. In the medium-term future, the impact of the virus will depend largely on its evolution.
SARS-CoV-2 is spreading uncontrollably around the world, and with every new replication, there’s a chance for mutations that could help the virus more effectively infect human hosts.
The human immune system, while protecting many of us from a serious illness, is also acting as an evolutionary crucible, putting pressure on the virus that selects for mutations that make it bind more effectively to human cells. The coming months and years will reveal how well our immune systems can keep up with these changes.
New SARS-CoV-2 variants also make widespread vaccination and other transmission-blocking measures, such as face masks and distancing, more crucial than ever. The less the virus spreads, the fewer opportunities it has to evolve.
We’re going to be able to manage it because of modern medicine and vaccines, but it’s not something that will just vanish out of the window.
ROY ANDERSONIMPERIAL COLLEGE LONDON
Current vaccines should still work well enough against emerging variants, such as the B.1.1.7 lineage first found in the United Kingdom, to prevent many cases of serious illness. Vaccines and natural infections create diverse swarms of antibodies that glom onto many different parts of SARS-CoV-2’s spike protein, which means that a single mutation can’t make the virus invisible to the human immune system.
Mutations may produce future variants of SARS-CoV-2 that partially resist current vaccines, however. In a preprint posted on November 19 and updated on January 19, Duplex and his colleagues show that mutations that delete parts of the SARS-CoV-2 genome’s spike protein region prevent certain human antibodies from binding.
“What I’ve learned from our own work is how deviously beautiful evolution is,” Duplex says.
Other labs have found that mutations in 501Y.V2, the variant first found in South Africa, are especially effective at helping the virus elude antibodies. Out of 44 recovered COVID-19 patients in South Africa, blood extracts from 21 of the patients didn’t effectively neutralize the 501Y.V2 variant, according to another preprint published on January 19. Those 21 people had mild to moderate cases of COVID-19, however, so their antibody levels were lower, to begin with, perhaps explaining why their blood did not neutralize the 501Y.V2 variant.
So far, currently authorized vaccines—which spur the production of high levels of antibodies—seem to be effective against the most concerning variants. In a third preprint published on January 19, researchers showed that antibodies from 20 people who had received the Pfizer-BioNTech or Moderna vaccines didn’t bind quite as well to viruses with the new mutations as they did to earlier variants—but they still bound, suggesting the vaccines will still protect against severe illness.
The new variants bring other threats as well. Some, such as B.1.1.7, appear to be more transmissible than earlier forms of SARS-CoV-2, and if left to spread uncontrollably, these variants could make many more people severely ill, which risks overwhelming healthcare systems around the world and even higher death tolls. Veldhoen adds that new variants also may pose a greater risk of reinfection to recovered COVID-19 patients.
Researchers are closely monitoring the new variants. If vaccines need to be updated in the future, Anderson says that it could be done quickly—in roughly six weeks for currently authorized mRNA vaccines, such as those made by Pfizer-BioNTech and Moderna. That timetable, though, doesn’t account for the regulatory approvals that updated vaccines would need to go through.
Anderson adds that depending on how the evolution of the virus progresses, lineages of SARS-CoV-2 may arise that are distinct enough that vaccines will need to be tailored to specific regions akin to vaccines for pneumococcus. To successfully guard against SARS-CoV-2 going forward, we will need a global monitoring network similar to the worldwide reference laboratories used to collect, sequence, and study variants of influenza.
“We’re going to have to live with it, we’re going to have to have constant vaccination, and we’re constantly going to have to have a very sophisticated molecular surveillance program to keep track of how the virus is evolving,” Anderson says.
The promise and challenge of widespread vaccination
Experts agree that transitioning beyond a pandemic depends on the prevalence of immunity, especially among older and more vulnerable populations. Younger people, especially children, will build up immunity to SARS-CoV-2 over a lifetime of exposure to the virus. Today’s adults have had no such luxury, leaving their immune systems naive and exposed.
The exact threshold for achieving population-wide immunity that slows down the virus’s spread will depend on how contagious future variants become. But so far, research of early variants of SARS-CoV-2 suggests at least 60 to 70 percent of the human population will need to become immune to end the pandemic phase.
This immunity can be achieved in one of two ways: large-scale vaccination, or recovery from natural infections. But achieving widespread immunity through uncontrolled spread comes at a terrible cost: hundreds of thousands more deaths and hospitalizations around the world. “If we don’t want to push forward vaccines and champion vaccines, we have to decide collectively how many old people we want to die—and I don’t want to be the one making that decision,” Duplex says.
Jeffrey Shaman, an infectious diseases expert at Columbia University, points out that the global push for vaccines also exposes existing inequities in global health. In a widely shared map from December, The Economist Intelligence Unit estimated that rich countries such as the U.S. will have widely accessible vaccines by early 2022, which may not happen for poorer countries in Africa and Asia until as late as 2023.
Efforts to vaccinate the developing world hinge, in part, on vaccines that can be stored with standard refrigeration, such as the vaccines under development by Oxford/AstraZeneca and Johnson & Johnson. (See the latest on COVID-19 vaccine development around the world.)
As of the week of January 18, according to a World Health Organization estimate, some 40 million COVID-19 vaccine doses have been administered around the world, mostly in high-income countries. In Africa, only two countries, Seychelles and Guinea, have started providing vaccines. And in Guinea, a low-income country, only 25 people have received doses.
Patients with IBD should receive COVID-19 vaccine, despite concerns
“For patients with IBD we would advocate, based on [International Organization for the Study of Inflammatory Bowel Disease (IOIBD)], that patients get vaccinated, acknowledging that there is a lack of data specifically in IBD patients,” Ryan C. Ungaro, MD, MS, gastroenterologist with Mount Sinai Hospital’s Feinstein IBD Center, told Healio Gastroenterology. “But we think the benefits outweigh the risks and based on prior experience with vaccinations in IBD patients.”
CDC and IOIBD recommend patients with IBD should receive the COVID-19 vaccine.
According to Ungaro, the CDC recommended immunocompromised patients should get the COVID-19 vaccine. Patients should be counseled that it is not yet known whether the safety and effectiveness of the vaccine in immunocompromised patients are the same compared with the general population.
“The major concern would be certain medications could lead to decreased response to the vaccine,” he said. “That is something that is going to need to be studied but right now the expert consensus is that IBD patients should get vaccinated against COVID-19.”
According to IOIBD recommendations, patients with IBD should receive the COVID-19 vaccine as soon as possible. Messenger RNA vaccines, replication vector vaccines, inactivated vaccines, and recombinant vaccines are safe to be administered in IBD patients, Ungaro said.
Additionally, the IOIBD said vaccines should not be deferred if an IBD patient is receiving immune-modifying therapies.
According to Ungaro, patients with IBD who take corticosteroids and get the vaccine should receive counseling that there may be a decreased systemic response. He said this needs to be studied further.
“Prospective studies are being planned to look at the real-world effectiveness and side effects of the COVID-19 vaccine in IBD patients,” Ungaro said. “This would require cohorts that are vaccinated and followed. Some studies are ongoing for that both in the United States and internationally. [Surveillance Epidemiology of Coronavirus Under Research Exclusion-IBD (SECURE-IBD)] is going to help support some of these efforts as well.”
Ungaro and his team at Mount Sinai in collaboration with the University of North Carolina developed the SECURE-IBD registry early in 2020 to monitor and report outcomes of COVID-19 in patients with IBD.
He said, “Physicians can encourage IBD patients to enroll in the Crohn’s and Colitis Foundation’s IBD Partners, they will be one of the sources for the prospective COVID-19 vaccine studies.”
Udo’s Choice® Super 8 Microbiotic
People liveing with crohns sisease can have a altered “microbiome” which means that the digestive bacteria thats in ther gut can be unbalanced ,that were takeing
Some experts maintain that using probiotics to restore the microbiome can allow a person with Crohn’s disease to reduce irregular immune responses and experience fewer symptoms.
They believe that adding healthful bacteria to the digestive tract, potentially by incorporating natural probiotic food sources to the diet, can reduce both intestinal inflammation and anomalies of the immune system. This could minimize symptoms of Crohn’s disease, such as gastrointestinal irritation, diarrhea, and stomach upset.
To see whether or not probiotics work for them, people with Crohn’s disease can keep a food diary and slowly incorporate some of these foods into their diet, noting any changes in their symptoms.
Probiotic foods include:
A person may also incorporate prebiotic foods into their diet. These are food sources that feed bacteria in the digestive tract and can promote their growth. These foods include onions, leeks, and asparagus.
Research has not proven that the probiotics in food can help reduce Crohn’s disease symptoms, so some people may wish to try taking a supplement first.
However, as long as someone does not have an allergy to foods that contain probiotics, incorporating them into the diet is a relatively risk-free method to try to improve overall health and help manage the disease.
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