Regarding case number one on the CSAP/parasitology homework: Having received the additional information from the review, this person is being encouraged to begin a different medication, Entyvio, for her ulcerative colitis …” And that’s one of the monoclonal antibody treatments or one of the biologics. “As a practitioner, how much should we push recommendations we feel may be beneficial to her versus acquiescing to what specialists are suggesting? I feel it would be my responsibility to let the patient know there are still some things to check out or rule out, such as HLA-B27, IBD connection along with increasing beneficial bacteria, using high-dose butyrate and increasing fermentable carbohydrates as well as reviewing a stricter anti-inflammatory diet. However, if this sounds too overwhelming, I may lose her as a patient to an easier protocol, i.e., the new medication.

This is a great question, and there are probably going to be different answers from different practitioners. Basically, the question is a patient [is] seeing you, [and] she’s also seeing a conventional gastroenterologist, and her conventional gastroenterologist is suggesting a monoclonal antibody, a biologic, to treat ulcerative colitis. How much do we push and say, “No, no. In Functional Medicine, you don’t need that” versus just saying, “Okay, let’s figure out how to work with that recommendation.” My personal approach is [that] this decision is not up to me. My personal feeling is this decision is up to the patient. It’s not my responsibility to push in one direction or the other. It’s my responsibility to help the patient make an informed decision. I don’t think I’ve ever told a patient not to start a biologic that feels best for him or her. It’s not my body, so it’s not my decision. My feeling is, okay, monoclonal antibody was recommended, so let’s think about, like, what are the risks and benefits of that, and I may not be the expert in that, so I am going to depend to some extent on the gastroenterologist, but I’m also going to look at UpToDate and I’m going to use what resources I have. Of course, I have limited prescribing experience with those because they’re not something that I prescribe, but I’m going to say, “Okay, what are the risks and benefits of the monoclonal antibody?” What options do we still have from a Functional Medicine perspective? How much of a flare are you in? And, again, especially if I have patients with ulcerative colitis [who are] having a lot of bleeding, especially if it’s to the point of really needing iron transfusions, that’s going to change the urgency. I mean, the degree of inflammation somebody is having does change the urgency, so I’m never 100% opposed even to biologics. I don’t think that they’re a good long-term answer for a number of reasons, and that’s not the question because they won’t go into that, but they can play a role. And so, I think that there is a place for us to be open to those, and I think what we really have to say is, well, what are the other options we have? And to be honest, I don’t think any of the options you listed here, like, let’s look at HLA-B27, let’s think about a really strict autoimmune Paleo diet, let’s think about high-dose butyrate or even butyrate enemas, that’s something else [we] might use in patients with ulcerative colitis. I think what you could say is you know these are not mutually exclusive, and so sometimes, when I tell people if they’re feeling pushed by their gastroenterologist to start a monoclonal or something, and they’re starting to feel like—because they feel scared sometimes. The symptoms can feel scary. “I’m feeling scared. I don’t know, my gastroenterologist is saying I [should] take this. Can I take this?” This would be my recommendation, I want to make sure the patient knows that I’m fine with them starting that because you want to keep the patient feeling like it’s a really safe space. It’s okay for them to choose whatever they want. In terms of their medication plan, and I say that partly because a lot of studies have been done, and most patients don’t tell their conventional doctors once they start supplements like fish oil, a lot of the botanicals and herbals that we prescribe, patients are not telling their conventional physicians [that] they’re taking these because they don’t want the backlash. They don’t want the eye rolling. They don’t want the judgment. And so, I want to make sure we’re not putting patients in a similar position where they tell us, “Oh, I’m taking this monoclonal antibody, this biologic” and if they’re fearful of my response, that’s not going to be a good relationship. I would just say, “I would support this decision. What can we do in addition to support you so that you might not need this biologic as long as might otherwise be necessary?” Hopefully, that gives you one idea in terms of how to approach it. But again, I would guess everyone has a different way of approaching it, and that’s just what I find works for me right now.