Open Source Apothecary At Home / Digestion

Inflammatory bowel disease: curcumin, boswellia and the rule about supplements

Some adjuncts have small trials. None of them replaces immunosuppression, and stopping treatment is what causes harm here.

remedy

Ulcerative colitis and Crohn's disease are immune-mediated, relapsing, and sometimes surgically treated. They are managed with aminosalicylates, immunomodulators, biologics and steroids, and the mortality and cancer risk depend on controlling inflammation. This page exists mostly to say: the adjuncts are adjuncts.

Curcumin has small randomised trials in ulcerative colitis as an add-on to standard treatment, with some evidence for improved clinical remission and a reasonable safety profile. The trials are small and the effect on hard endpoints is not established. It is the best-supported adjunct in this handbook for IBD.

Boswellia has small trials in IBD as well, of lower quality.

Fish oil, probiotics, and various plant extracts have been studied with inconsistent results.

The rule that matters. A person with IBD who stops their maintenance treatment because a supplement is "working" is the scenario that ends in a flare, a hospital admission, or surgery. Any adjunct is added to the treatment, not substituted for it. And any new supplement is a change to a disease where the liver and kidney are already under surveillance — tell the gastroenterologist.

The red flags here are the most important part of the page. A severe flare, a toxic megacolon, or an obstruction are emergencies that present as worsening abdominal pain, distension, fever and bleeding, and a person with IBD needs to know their own baseline and their own escalation plan.

What the studies found

Preparation

Curcumin — and the bioavailability problem

• Curcumin is poorly absorbed on its own. Trials have used formulations designed to overcome it, or combined curcumin with piperine (black pepper extract), which inhibits the glucuronidation and CYP3A4 that clear it.
• A common household approach: 1/4 teaspoon of ground turmeric with a pinch of ground black pepper and a fat source (the curcuminoids are fat-soluble), taken with food. This is nowhere near the trial doses.
• Do not use high-dose curcumin with anticoagulants or with a drug metabolised by CYP3A4, because piperine raises co-administered drug levels.
• Curcumin can cause GI upset and, rarely, liver injury.

Boswellia

• Standardised extract per product label; trials used 300-400 mg of boswellic acids two to three times daily
• Generally well tolerated; can cause GI upset

Fish oil

• Anti-inflammatory but not a treatment for IBD; the trials are inconsistent

What not to do

• Do not stop or reduce prescribed maintenance treatment to test an adjunct
• Do not start a supplement without telling the gastroenterologist

Cautions and interactions

• Do not substitute any of this for maintenance treatment. Flares and surgery are the consequences.
• Curcumin with piperine raises the levels of drugs cleared by CYP3A4. Check every medicine.
• Curcumin and boswellia can increase bleeding risk with anticoagulants.
• Curcumin has been implicated in liver injury in a small number of reports.
• Iron supplementation in IBD is a clinician's decision — inflammation changes iron handling and oral iron can worsen symptoms.

When this is not a self-care problem — get help

• Severe abdominal pain with distension, fever, and reduced bowel movements or bleeding — possible toxic megacolon or obstruction; emergency care.
• A flare with more than 6 bloody stools a day, fever, or feeling faint — urgent gastroenterology assessment.

Related

• Herbal liver injury, and the plant that ends the matter
• Iron deficiency: the right way to take iron, and the reason it may not be a supplement problem
• Turmeric, curcumin and osteoarthritis
• Herb-drug interactions: the ones with numbers behind them

Sources

1. Curcumin and Curcuma longa Extract in the Treatment of 10 Types of Autoimmune Diseases: A Systematic Review and Meta-Analysis of 31 Randomized Controlled Trials. Frontiers in immunology 2022; doi:10.3390/pharmaceutics13101715 PubMed 35979355
2. Efficacy and safety of adjuvant curcumin therapy in ulcerative colitis: A systematic review and meta-analysis. Journal of ethnopharmacology 2022; doi:10.1016/j.jep.2022.115041 PubMed 35091013
3. Effects of curcumin supplementation on inflammatory biomarkers in patients with Rheumatoid Arthritis and Ulcerative colitis: A systematic review and meta-analysis. Complementary therapies in medicine 2021; doi:10.1016/j.ctim.2021.102773 PubMed 34478838
4. Curcumin therapy for ulcerative colitis remission: systematic review and meta-analysis. Expert review of gastroenterology & hepatology 2020; doi:10.1080/17474124.2020.1808460 PubMed 32772752
5. Efficacy of adjuvant curcumin therapy in ulcerative colitis: A meta-analysis of randomized controlled trials. Journal of gastroenterology and hepatology 2020; doi:10.1111/jgh.14911 PubMed 31696975