Treatment of Irritable Bowel Syndrome

DRUGS & NATURAL REMDIES

by William B. Salt II, M.D. and Neil F. Neimark, M.D.

The Science of Medical Treatment for IBS

Jailwala, Imperiale and Kroenke have written a review of scientific studies published up to the year 2000 on drug treatment of IBS (Annals of Internal Medicine, 2000;133:136–147). These researchers concluded the following:

·       Antispasmodics/smooth muscle relaxant drugs are beneficial when pain is the predominant symptom.

·       Loperamide (brand name Imodium; generic drugs available) is effective for diarrhea but not for pain.

·       Bulking agents improve constipation and stool consistency but do not improve pain.

·       Chinese herbal medications and other medications that have been studied sporadically and in small trials need to be further investigated before specific conclusions can be drawn.

·       Some antidepressant drugs appear to be effective in the treatment of some of the symptoms of functional gut disorders.

Additional studies support the value of antispasmodic drugs for the treatment of abdominal pain (Alimentary Pharmacology & Therapeutics, 1994;8:499–510 and 2001;15:355–361).

Medical treatment for patients with IBS is usually directed to the predominant symptoms, which include abdominal discomfort and pain, diarrhea, constipation and bloating/distention (Drossman D.A., Whitehead W.E., Camilleri M., et al. “Irritable Bowel Syndrome: A Technical Review for Guidelines Development.” Gastroenterology, 1997;112:2120–37).

Abdominal discomfort and pain

When the main symptom of IBS is abdominal pain, drug choices include antispasmodics, analgesic drugs (non-narcotic and narcotic), antidepressant drugs (see later discussion) and newer 5-HT drugs (see later discussion).

Antispasmodics.  There are three classes of antispasmodics, or drugs that decrease gut contraction and spasm.

·       1. Anticholinergics work by blocking the effects of the parasympathetic branch of the autonomic nervous system. Examples include dicyclomine (Bentyl is a brand name), hyoscyamine (brand names Anaspaz, Levsin, Levsinex and NuLev), glycopyr-rolate (brand name Robinul), methscopolamine bromide (brand name Pamine) and propantheline (a brand name is Probanthine). One drug (a brand name is Librax) is an anticholinergic drug called clidinium combined with a benzodiazepine antianxiety drug called chlordiazepoxide. Another (brand names Donnatal and Donnatal Extentabs) combines two anticholinergic drugs called atropine and scopolamine with a barbiturate antianxiety drug called phenobarbital.

·       2. Direct smooth muscle relaxants act directly upon the smooth muscle of the gut. Studies show that the direct smooth muscle relaxants may be the most effective of the antispasmodics, but these drugs are not available in the United States. Examples of direct smooth muscle relaxant drugs include octylonium, mebeverine and trimebutine.

·       3. Peppermint oil is thought to work by decreasing calcium entry into muscle cells, resulting in muscle relaxation. Enteric-coated preparations may be preferable to unprotected peppermint because they allow delivery of the peppermint oil to the colon. Peppermint oil may or may not be effective. Scientific studies of the oil’s use are inconclusive.

Analgesic drugs.  Analgesic drugs are either non-narcotic or narcotic.

·       Non-narcotic.  Non-narcotic analgesic drugs (aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, also known as NSAIDS) are usually of little benefit in treating the abdominal pain of IBS. Tramadol (brand name Ultram), is a non-narcotic analgesic drug that binds to opiate receptors in the brain and alters serotonin and norepinephrine re-uptake, which inhibits the transmission of pain signals to the brain through ascending pathways from the body and gut. It is best to begin with a very low dosage and gradually increase it over several days to reduce the likelihood of unacceptable side effects (mainly nausea).

·       Narcotic.  Narcotic analgesic drugs are usually not prescribed for continuous treatment because of possible development of physical dependency or addiction and unwanted side effects, such as drowsiness and interference with clear thinking. Furthermore, continuous narcotic use can actually increase pain sensitivity and also alter gut motility, leading to severe constipation. This is called the “narcotic bowel syndrome” (Annals of Internal Medicine, 1984;101:331–334). Keeping these cautions in mind, narcotic analgesic drugs are occasionally used to relieve intermittent attacks of more severe pain.

Diarrhea

There are two main functional gastrointestinal disorders where diarrhea is a prominent symptom: (1) chronic functional diarrhea and (2) the more common diarrhea-predominant IBS, or D-IBS.

Treatment choices include the opioid agonists loperamide (a brand name Imodium; generic available) and diphenoxylate (a brand name Lomotil; generic available). Diphenoxylate also contains atropine, which is an antispasmodic discussed earlier.

Two drugs that are used to lower blood cholesterol can be helpful for some patients with chronic diarrhea, especially if the problem tends to occur in the morning, is triggered by meals or develops after surgical removal of the gallbladder. These drugs are cholestyramine (brand name Questran; generic available) and colestipol (brand name Colestid; generic available).

Narcotic drugs, such as codeine, are opioid agonists and have consti-pation as a potential side effect, so they may relieve diarrhea. However, because they cross into the brain, they can have unwanted side effects of sedation and drowsiness, and they can lead to physical dependency and addiction (see earlier discussion of narcotic analgesics).

Unless a dietary factor can be identified as a trigger or cause of chronic diarrhea, opioid agonists are usually recommended first. Studies show that loperamide reduces the urgency and frequency of bowel movements in patients with diarrhea-predominant IBS. Furthermore, loperamide can increase stool consistency and strengthen anal sphincter tone, which can be helpful if fecal incontinence is a problem. Loperamide does not get into the brain through the blood-brain barrier and is usually preferred over other opioids, such as codeine or diphenoxylate. However, none of these agents have been shown to relieve the pain associated with IBS. The drugs can either be taken regularly or on a prophylactic basis. If a “morning rush” occurs, then the drug could be taken at bedtime.

A study has shown that tricyclic antidepressant drugs (TCAs) may relieve diarrhea and associated pain in some patients with IBS, in part by their anticholinergic effects. Refer to the preceding discussion on “Anticholinergics” and to the later discussion on “Antidepressant Drugs.”

Constipation

There are two functional gut disorders where constipation is a prominent symptom: (1) constipation-predominant IBS, or C-IBS and (2) functional constipation. Remember that the normal frequency of bowel movements ranges from three per day to three per week.

When constipation is the predominant symptom, the first step for most patients is a trial of adequate dietary fiber intake. Additional options include laxatives and medications.

Dietary fiber and fiber supplements (bulk agents or bulk laxatives).  Most people, including doctors, do not appreciate the potential benefits of adequate fiber intake and how to incorporate fiber into the diet. Most who have mild to moderate uncomplicated constipation improve when fiber intake is increased. Those who either fail to respond to increased fiber intake, cannot tolerate it or require additional help may need to utilize laxatives.

Laxatives.  There are two types of laxatives, osmotic and stimulant. Osmotic laxatives are not absorbed and most require a prescription. They soften the stool and have an onset of action of one to three days. One type of osmotic laxative is polyethylene glycol, or PEG (a brand name is Miralax). Another is unabsorbed carbohydrate (lactulose and sorbitol). Glycerine suppositories are available without prescription.

Stimulant laxatives interfere with absorption and motility and are available without prescription. They have an onset of action of six to twelve hours and produce a soft to semi-fluid stool. They include saline laxatives (brand names Milk of Magnesia and Citrate of Magnesia); diphenylmethane derivatives (brand name Dulcolax); and anthraquinone derivatives (senna, cascara sagrada and aloin).

Anthraquinones are widely available. They may also be included in many “natural” remedies (see later discussion) that are advertised as colon health products, herbal laxatives and even teas. These laxatives may or may not be identified in the list of ingredients. If they are identified, they may be described as harmless and “natural,” such as locust plant or Cassia angustofolia (senna). Make sure to tell your doctor if you are taking one of these products.

·       Chronic use of laxatives.  The belief that stimulant laxatives can damage the colon is probably untrue. This is the conclusion drawn by Dr. Arnold Wald, a gastroenterologist at the University of Pittsburgh Medical Center, who is an expert on constipation. We agree with his recommendations that chronic use of laxatives is not harmful when they are used appropriately. Remember that most people with constipation can be adequately relieved with adequate dietary fiber intake. Osmotic laxatives can be used on a daily basis. If necessary for symptom relief, stimulant laxatives should be used no more often than two to three times weekly (4^th International Symposium on Functional Gastrointestinal Disorders, March 30–April 2, 2001, Milwaukee, WI).

Bloating and distention

No drug therapies have been confirmed to benefit bloating and distention; however, antidepressant drugs may help (see next section on Antidepressant Drugs). A recent study suggested that patients who took one capsule of pancreatic enzyme supplement prior to eating high-fat meals (brand name Creon 10; available by prescription) significantly minimized their abdominal bloating, flatulence and nausea (Digestive Diseases and Sciences, July, 1999).

Antidepressant Drugs

Antidepressants are commonly prescribed for IBS and other functional gut and bodily symptoms and syndromes, even though the Food and Drug Administration (FDA) does not specifically approve them for this purpose unless depression is present. This is called an “off-label” indication. Nevertheless, antidepressants can be helpful in bringing symptom relief in IBS and other functional syndromes, such as fibromyalgia (American Journal of Medicine, 2000 Jan;108(1):65–72; Journal of General Internal Medicine, 2000 Sep;15(9):659–66). If depression is present, then a full antidepressant drug dose is necessary. If depression is not present, then lower doses may be effective.

At Digestive Disease Week 2001 in Atlanta, Georgia, University of North Carolina gastroenterologist Douglas A. Drossman said that, “The use of antidepressants in IBS and other GI disorders is growing.” When symptoms become repetitive, severe and/or are associated with alteration in quality of life, antidepressant drugs can be considered.

Antidepressants have effects on gut motility (contractions) and sensation and also may have pain modulatory benefits. Antidepressant drugs are not addictive. The following list gives examples of antidepressants in each of three classes. Brand names are given in parentheses

Tricyclics (TCAs)

Amitriptyline (Elavil)

Clomipramine (Anafranil)

Desipramine (Norpramin)

Doxepin (Sinequan)

Imipramine (Tofranil)

Nortriptyline (Pamelor)

Selective Serotonin Re-uptake Inhibitors (SSRIs)

Citalopram (Celexa)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Unique Property Antidepressants

Buproprion (Wellbutrin)

Mirtazepine (Remeron)

Nefazedone (Serzone)

Trazodone (Desyrel)

Venlafaxine (Effexor)

Questions for you and your doctor

Antidepressant drugs may be of benefit in the treatment of abdominal pain and discomfort associated with IBS; however, the tricyclic anti-depressants (TCAs) have proven to be more effective than the selective serotonin re-uptake inhibitors (SSRIs) in the small number of scientific studies that have been conducted. The efficacy of SSRIs in treatment of functional gut syndromes such as IBS is currently being investigated. In clinical practice, finding the best drug is often a matter addressing several important questions:

·       Are you depressed, along with your digestive symptoms? If so, then an antidepressant drug dose will be needed, because the presence of depression can magnify and amplify your symptoms. If you are not depressed, then lower antidepressant drug doses may be effective.

·       Do you have previous experience with antidepressant drugs? If a drug helped before, it may be wise to select the same one again. But, if a specific antidepressant was not helpful before or caused unacceptable side effects, then it doesn’t make much sense to try it again.

·       Do you have concerns about taking antidepressants? If you have taken antidepressant drugs previously, inform your doctor about which drug or drugs that you have taken, whether they helped or whether they caused unacceptable side effects. Also, discuss any reluctance that you may have regarding taking antidepressants. The purpose of treatment with an antidepressant drug is to help you to feel better and not to alter your mind adversely. Antidepressant drugs are not addictive.

·       Do you also have other functional symptoms and/or syndromes, such as fibromyalgia and interstitial cystitis? If so, then antidepressant drugs may be helpful in reducing or relieving more than just the digestive symptoms.

·       Do you have a family member or family members who have benefited from a specific antidepressant or had unwanted side effects? Remember what you have learned about your family history. You may want to take this into consideration when you and your doctor select an antidepressant.

·       Do you have any significant health problems, especially with your heart and circulation, liver and kidneys? For example, it may be important to avoid the TCAs if you have heart arrhythmia.

·       What are your predominant symptoms?

·       Pain or discomfort: TCAs may be the best initial choice.

·       Diarrhea: some antidepressants have constipation as a side effect and could be helpful for diarrhea.

·       Constipation: some antidepressants are more likely to cause diarrhea, which might improve the constipation. TCAs have not been shown to be beneficial in treatment of constipation and may either cause or aggravate the condition.

·       Sleeping problems: some antidepressants are more helpful in promoting sleep than others, and some may actually interfere with sleep.

·       Sleepy or sluggish: some antidepressants can boost energy.

·       Nervous or jittery: some drugs can bring a calming effect.

Be patient

It can take several weeks for an antidepressant to take effect. If treatment is stopped too soon, then it may appear that the treatment did not work. If you experience side effects, discuss them with your doctor. Most side effects will either diminish or go away completely after several days, or they can be reduced temporarily by lowering the dose. Furthermore, the decision to continue treatment or consider a change of medication can be re-evaluated at a later appointment. Since everyone is different, trying one or more different antidepressant drugs may be necessary in order to find the one that is best for you.

Unwanted side effects

Space will not permit a detailed discussion of potential antidepressant drug side effects, but a common one is sexual dysfunction. Unfortunately, some of the antidepressant drugs interfere with sexuality and sexual function by reducing libido or causing difficulty with achievement of erection or orgasm. The antidepressant drugs that are less likely to cause this problem are buproprion (brand name Wellbutrin), mirtazepine (brand name Remeron), Nefazedone (brand name Serzone) and possibly citalopram (brand name Celexa).

Antianxiety Drugs (Anxiolytics)

Anxiety may be associated with IBS. If so, then antianxiety drugs, called anxiolytics, may be helpful.

Benzodiazepines

Benzodiazepines are commonly used in the treatment of anxiety, but they can cause drowsiness, sedation, memory impairment and interactions with other drugs and alcohol. Furthermore, physical dependency can develop, so that physical withdrawal symptoms and rebound anxiety can occur upon discontinuation. It is for this reason that discontinuation of long-term benzodiazepine treatment requires a slow tapering of dose. Finally, benzodiazepines may cause or aggravate depression. For these reasons, they are usually prescribed only when anxiety is moderate to severe. The most commonly prescribed benzodiazepines (brand names in parentheses) are clonazepam (Klonopin); diazepam (Valium); lorazepam (Ativan); and alprazolam (Xanax). Generic versions of each are available.

Buspirone (brand name is BuSpar)

Buspirone is a non-benzodiazepine drug that is approved for treatment of chronic anxiety. It is less likely to cause drowsiness and sedation than benzodiazepines, but dizziness and nausea can occur during initial treatment.

Antidepressant drugs

Antidepressant drugs can be used in the treatment of anxiety.

Newer Drugs

Newer drugs have been developed that are agonists (drugs that enhance) and antagonists (drugs that block) the effects of the neurotransmitter 5-HT (serotonin) in the gut.

Diarrhea-predominant IBS

Alosetron (brand name Lotronex) is a 5-HT3 antagonist used to treat diarrhea-predominant IBS in women (it has not been shown to be effective in men during research). It was withdrawn from the U.S. market in 2000 because of concerns over its safety. The most common side effect was constipation, but a type of colon inflammation called ischemic colitis was found to be associated with, although not definitely caused by, the drug.

Constipation-predominant IBS

Tegaserod (brand name Zelnorm) is a 5-HT4 agonist designed to treat constipation-predominant IBS. It should be a promising treatment for C-IBS, but it has not yet been approved for use in the United States by the FDA. Scientific studies have shown that if side effects do occur, they are minor (headache, diarrhea). No cases of ischemic colitis have been reported.

“Natural” Remedies

The placebo response is evidence of the remarkable self-healing capacity that we all have. Howard Brody, M.D., is a physician at Michigan State University who has written a book called The Placebo Response: How You Can Release the Body’s Inner Pharmacy for Better Health. He defines the placebo response as “a change in the body (or the body-mind unit) that occurs as the result of the symbolic significance that one attributes to an event or object in the healing environment.” As UCLA gastroenterologist Dr. Emeran Mayer has written, “If we are honest with ourselves, treatment practices do not necessarily have to be better than placebo to find a useful place in medical practice, and honest practitioners have used this approach to the benefit of their patients for many years. Conversely, practitioners who eschew the healing arts in favor of only offering their patients scientific evidence-based therapies may be justifiably accused of doing their patients a serious disservice” (The Neuro-biology Basis of Mind Body Medicine, The International Foundation for Functional Gastrointestinal Disorders, 2001).

Most of the evidence for efficacy of “natural” remedies and herbal products is empirically derived, which means that recommendations and usage are based upon repeated experience and observation throughout history. Few have been subjected to the rigors of scientific testing. But even if no better than placebo, “natural” remedies may be helpful. Numerous products are now available, marketed as daily dietary supplements, in accordance with the Dietary Supplement Health and Education Act (DSHEA). DSHEA products carry nutrition support statements that may include claims regarding the effects of the product on the structure or function of the body. In doing so, they must carry the following disclaimer: “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”

General Recommendations about “Natural” Medicines and Herbals

If you decide to take natural remedies or herbal medicines, here are our recommendations.

·       Don’t take them if you don’t need them.

·       You may need to experiment with herbal remedies, since most of the evidence for efficacy is empirical, meaning that recommendations and usage are based upon repeated experience and observation throughout history. Few have been subjected to the rigors of scientific testing. Allow your experience to be your guide and use only those remedies that provide you with consistent benefits.

·       Be sure to let your doctor know about it, particularly since some of these treatments can react with prescription drugs.

·       Herbal products may be contaminated or adulterated, and they may not contain advertised amounts of the active ingredients. So, purchase reputable brands that also advertise the purity of their ingredients. Search for herbal preparations that have been “wildcrafted” (harvested from wild stands) or cultivated organically.

·       Discontinue use if you have an adverse reaction.

·       Tinctures (alcohol based) and freeze-dried extracts of herbals are usually the best preparations to purchase.

·       Loose herbs that are sold in bulk and powdered herbals within capsules are less likely to be effective.

Products

Here is a brief description of some of the most commonly used “natural” remedies and herbal products.

Acidophilus.  Acidophilus is a probiotic (see later discussion) that consists of dried or liquid cultures of live bacteria that sour milk and are considered beneficial or “friendly” to the GI tract. Health food stores carry acidophilus in preparations that have much higher concentrations of the bacteria than are found in yogurt and acidophilus milk.

Used for: IBS, diarrhea or to avoid diarrhea when taking antibiotics

Aloe or aloe vera.  The clear gel from the aloe plant is used in many skin lotions, creams and cosmetics because of its moisturizing properties. Aloe vera juice, sold in health food stores, can be taken internally. If the dose is too high, it can have a laxative effect. A reasonable amount to try is 1 teaspoon after meals. The fresh gel can be mashed up in fruit juice. There is variation in palatability, so it may be necessary to try different brands.

Used for: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)

Aromatherapy.  The five senses send information to the limbic system. Aromatherapy is based upon the fact that sense of smell is the only sense that is wired directly into the limbic system. Scents that are purported to be helpful in IBS include peppermint, eucalyptus, lavender and rose oil. A certified aromatherapist ensures use of essential oils and not synthetic chemicals.

Used for: IBS

Beano (brand name).  Beano is manufactured by AKPharma, Inc., the manufacturers of Lactaid and Prelief. Beano contains an enzyme called alpha-galactosidase that digests the indigestible carbohydrate (raffinose) contained in beans and some vegetables. Beano has no effect on gas associated with other carbohydrates, such as sorbitol, lactose, wheat and fiber. It cannot be added to food while it is being cooked, since heat degrades the enzyme.

Used for: Flatulence

Calcium glycerophosphate (brand name Prelief).  The manufacturer of Prelief, AKPharma, Inc., advertises that, “Prelief takes acid out of food. Prelief reduces the acid in all food and beverages so you can enjoy a more comfortable diet.”

Used for: Food sensitivity, IBS, interstitial cystitis

Chamomile.  Chamomile is the dried flowers of the perennial chamomile plant. It is available as an extract, oil and tea.

Used for: Nausea, dyspepsia, IBS, anxiety

Charcoal.  Activated charcoal tablets or capsules (brand names include Charco Caps and Charcoal Plus) may help provide relief from flatulence by reducing intestinal gas.

Used for: Flatulence

Chinese herbal medicine.  Chinese herbal medicine has been used in China for centuries in the treatment of IBS symptoms. A recent scientific study published in the Journal of the American Medical Association (1998;280:1585–1590) concluded that Chinese herbal medicine may be beneficial in the treatment of IBS. The product used was supplied by Mei Yu Imports.

Used for: IBS

Chlorophyllin copper.  Products that contain chlorophyllin copper (brand names include Nullo and Derifil) may help to reduce the offending odor of flatus.

Used for: Malodorous flatulence

Fennel.  Fennel (Foeniculum vulgare) includes the seeds, leaves and roots of the fennel plant. It is available in plain seeds, sugar coated seeds, extract, oil and capsules. The adult dose is one half-teaspoon of fennel seeds chewed after eating or whenever symptoms are bothersome, or as recommended on the product label.

Used for: Rectal gas and flatulence

Flaxseed.

Used for: Source of fiber and omega-3 fatty acids

Ginger.  Ginger is a spice that is available in fresh form from supermarkets, as candied ginger, honey-based ginger syrups, tinctures and powdered extract in capsules.

Used for: Nausea, dyspepsia

Kava.  Kava is a derivative of a plant indigenous to the South Sea Islands (Piper methysticum) that has a mild relaxant and antianxiety effect.

Used for: Anxiety

Lactase enzyme.  Brand names of products containing lactase enzyme for lactose intolerance include Lactaid, Dairy-Ease and Lactrase.

Used for: Lactose intolerance

Passion flower.  Passion flower is an herbal made from a Native American plant (Passiflora incarnata) that has a mild relaxant effect.

Used for: Anxiety

Peppermint.  Peppermint is available in capsules that have a protective coating that resists digestion by the stomach acid so that the peppermint can be released in the colon. There are several brands available, but we recommend the brand names of Mintacin or Peppermint Plus (manufactured by Enzymatic Therapy, Inc; www.enzy.com).

Used for: IBS

Probiotics.  ”Probiotic” is the term used to describe health-promoting “friendly” bacteria ingested orally. These bacteria in the intestine purportedly provide a protective effect only when a proper balance is maintained among all the different bacteria that normally reside in the intestine. If normal bacteria become depleted or the balance is disturbed by diet, infection, antibiotic use, lifestyle changes or stress, then potentially harmful “unfriendly” bacteria can overgrow and become established, leading to digestive and other health problems. These harmful bacteria are alleged to have the ability to cause gastrointestinal problems such as diarrhea, abdominal pain and/or bloating if not kept in check by the beneficial bacteria. Furthermore, probiotics supposedly promote digestive health, balance and function and help maintain a healthy balance of “good” bacteria in the digestive tract.

Probiotics are credited with an impressive list of therapeutic and prophylactic attributes. The probiotics industry is flourishing, and interest in establishing scientific credibility has attained importance for many companies and scientists. Probiotics are the subject of considerable scientific research. For now, if you decide to try a probiotic, the most commonly recognized probiotics are the lactic acid bacteria that include lactobacilli, streptococci and/or bifidobacterium. Some commercially available products include Lactobacillus acidophilus (many brands available); Lactobacillus reuteri (brand name Probiotica), manufactured by McNeil, the company that makes Imodium; Lactobacillus GG (brand name Culturelle), made by CAG Functional Foods—a ConAgra Company; and Saccharomyces boulardii.

Used for: A variety of gut symptoms and digestive health

SAMe (s-Adenosyl methionine).  This dietary supplement is a prescription drug for depression in Europe, but it is available in the United States without prescription and promoted as a natural product for the treatment of depression or arthritis. SAMe contains an important compound that is produced by all living cells, which is involved in the regulation of several hormones and neurotransmitter chemical messengers, such as serotonin and epinephrine. SAMe is expensive.

Used for: Depression (not severe or associated with suicidal ideation) and arthritis

Simethicone.  Simethicone is a foaming agent that joins gas bubbles in the stomach, which may increase the amount of gas that can be belched away. Brand names include Gas-X, Mylanta Gas and Phazyme. Simethi-cone has no effect on intestinal gas.

Used for: Belching

Slippery elm.  Slippery elm is obtained from the inner bark of the red elm tree and is said to restore the normal mucus coating on irritated tissues. Slippery elm lozenges can be found in most grocery stores.

Used for: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)

St. John’s wort.  St. John’s wort (Hypericum perforatum) may be useful in treating depression, although scientific studies are incon-clusive.

Used for: Depression (not severe or associated with suicidal ideation)

Triphala.  Triphala is an Ayurvedic Indian mixture used to treat constipation and poor bowel tone. Indian practitioners of Ayur-vedic medicine recommend two Indian brands: Dabur and Hammdar. The dose is two capsules per day or as recommended by the manufacturer.

Used for: Constipation and poor bowel tone

Valerian.  Obtained from the root of an European plant, Valeriana officinalis was the main sedative and hypnotic in use in Europe and America before the invention of barbiturates in the early twentieth century.

Used for: Sleep aid

From Irritable Bowel Syndrome and the MindBodySpirit Connection by William B. Salt II, M.D. and Neil F. Neimark, M.D.. Copyright © 2002 by William B. Salt II, M.D. Excerpted by arrangement with Parkview Publishing. $19.95. Available in local bookstores or call 888-599-6464 or click here.