Annette is a patient born in Argentina who I saw in consultation for Crohn’s disease. Like most people from that part of the world, she received the bacillus Calmette–Guérin, or BCG, vaccine against tuberculosis as a child. Since the vaccine is prepared from a strain of live tuberculosis that has lost its virulence in humans, one of the possible side effects is a false positive skin test for tuberculosis, which is exactly what happened to Annette when she was screened for tuberculosis in middle school. As a result of the positive test, she was treated for active tuberculosis infection with three antibiotics for a total of nine months, even though she never had any signs or symptoms of tuberculosis, and an X-ray of her lungs failed to show any evidence of the disease.
In her senior year of high school Annette developed abdominal pain, diarrhea, and weight loss. She was diagnosed with Crohn’s disease, which we now know can be triggered by excessive antibiotic use, especially when exposure occurs early in life, as was the case with Annette. Shortly after diagnosis she was started on a series of drugs that included immune-modulating agents. Her disease improved significantly, although she continued to have occasional episodes of mild abdominal pain and difficulty gaining weight. Ten years after being diagnosed with Crohn’s, Annette decided she wanted to start a family. She and her husband weren’t comfortable with her getting pregnant on the medications she was taking because of the potential risk to the fetus, so before trying to conceive she embarked on a dietary regimen that excluded processed foods and refined sugar that had worked for a friend with IBD. The diet worked for Annette, too, and within four months she had successfully tapered off all her medications.
Her former gastroenterologist had recommended she resume all her medications immediately after her pregnancy, but she was still in remission and feeling well a year after delivering a healthy baby boy, and she wanted to continue trying to control her Crohn’s with diet alone. I liberalized her diet a bit, adding in some of the things she missed and wanted to try to reintroduce, and three years after starting the diet Annette remains in remission on no medications.
I still have a prescription pad, but I try to use it as little as possible— not because the drugs don’t work but because risks like infection and cancer and the fact that many of these drugs cross the placenta and are present in breast milk tend to outweigh the benefits for the more effective therapies. The less potent drugs have fewer side effects, but they also don’t work as well—in fact, some have a response rate that’s the same as treatment with a placebo, or sugar pill! Interestingly, we use the same pool of drugs to treat IBD that we employ for other autoimmune conditions such as rheumatoid arthritis and psoriasis, and the dietary therapy that works so well for our patients’ intestinal problems frequently improves their other coexisting autoimmune problems, suggesting a common mechanism of causation and cure. The response rate to dietary therapy in patients in our practice with Crohn’s and ulcerative colitis is much higher than that of the potent (and potentially toxic) biologic agents – and free of any harmful side-effects!
This excerpt first appeared in Dr. Chutkan’s book, The Microbiome Solution (Penguin 2015).