Best treatment options for PD during an exacerbation of Inflammatory Bowel disease (IBS): By Dr. De Leon

As I have been dealing with severe Gi complications from both PD and history of ulcerative colitis, I thought I would cover this topic today on how to manage living with both illnesses. Not an easy task I assure you. As you may know, people with inflammatory bowel disease are at higher risk of having PD. But having PD can also compromise our immune systems making flare ups and exacerbation’s much more common.
Not only are colitis exacerbation’s a medical emergency due to possible severe dehydration that can occur but depending on the severity of disease and location down the Gi tract may require surgery. On top of the colitis Parkinson’s symptoms can also spin out of control lengthening recovery period and possibly prolonging hospitalization and rehab if we are not careful.

First, what is IBS- term used to describe disorders involving chronic inflammation of gi tract.
These compromise 2 diseases:

Ulcerative colitis (UC) – only involves colon and rectum
Crohn’s disease- involves the entire digestive tract

Complications of BOTH:
• Colon cancer need colonoscopy every 10years or more often
• Skin, eye and joint inflammation- PD can also cause joint pain in shoulder, hip and can cause eczema.
• Primary sclerosing cholangitis -scaring of the bile ducts leading to liver damage
• Increase blood clots- remember that PD increases risk of clots especially in those of us with migraines.

UC
• Toxic megacolon- rapid expansion and swelling of colon extremely serious condition
• Perforated colon
• Severe dehydration

Crohn’s
• Ulcers
• Malnutrition
• Bowel obstruction

Treatments
• Nutritional support
• Calcium and vitamin D supplement especially important since we as PD patients already have Vitamin D deficiency
• Iron supplement- we may also already be anemic due to B12 deficiency
• Antidiarrheal –
• Desetin for irritation of your hiney
• Wear adult diapers for security till symptoms resolve
• Pain relievers- like Tylenol – avoid Nsaids like Motrin which make symptoms worse
• Antibiotics
• Anti-inflammatory drugs steroids and aminosalicylates (e.g. Asacol), balsalazide (Colazal) and olsalazine (Dipentum)
• Immunosuppressants methotrexate, azathioprine, cyclosporine-

 Important to note that some of these medicines cause b6 and b12 deficiency and can cause numbness and tingling which can already be present in PD. They can also increase the shakiness, can also cause nausea, vomiting, increase in BP, and cause dizziness. Therefore, it is extremely important to have a direct communication between your neurologists and Gi doctor. Especially, if these medicines will be taken for a long period of time. These can also cause osteoporosis so may have to take medication to prevent given that PD meds already increase risk of this. Plus can worsen headaches many of us already have migraines with PD.

• Tumor necrosis factors (TNF) e.g. Humira, Entyvio, Tyrabri, Stelara
• Dietician consult if losing too much weight
• Add multivitamin can be a melt
• May need to increase nausea meds since many PD drugs also cause nausea. Take ginger, mint, and peppermint teas to help with this. I have been on a diet of peppermint and mint tea for last 3 weeks along with Zofran to control severe nausea.

Diet
• Limit dairy products
• Low fat foods
• Eating fiber can exacerbate symptoms – steam vegetables instead of raw

 Things in cabbage family like cauliflower and broccoli usually make things worse
 Avoid nuts, fresh fruit especially those with skin like apple –if you do eat peel first, no popcorn, seeds or corn. Things like watermelon, pineapple, bananas,
• Avoid caffeine, alcohol and spicy foods- there goes my coffee, sweet tea, Mexican food and margaritas!!! My, my, what am I to do?

• Eat small meals -5-6 meals – this will help both PD and colitis
• Drink lots and lots and lots of water!!!
Can have jell-o, Popsicle, Gatorade, even Iv fluids if necessary to avoid dehydration

PD medications will have to be given either at higher doses to compensate for loss during exacerbation or be given in alternate route. For instance, if colitis is severe and intractable perhaps pump and /or DBs would be best. During the exacerbation you may also need to switch levodopa to oral disintegrating I.e. Parcopa, use 24 hour amantadine (Gicovri), Neupro patch and apomorphine either injection or melt strip once available. This will keep you from losing effect of medication because of gi malabsorption and diarrhea. We don’t want to decrease medication dose because not only will you have risk of falling but also of aspiration which would only complicate matters.
Best thing is be proactive in avoiding things that can trigger an exacerbation not always possible to control but we can alter our life style to reduce chance. This means decreasing stress through meditation, exercise, eating small meals regularly on time, drinking lots of fluids and sleeping well. Don’t forget routine check -ups!

Source:

Copyright@2018
all rights reserved by Maria De Leon

The Need for Vitamin D in PD: By Dr. De Leon

“Them bones…them bones..”

Now that we just spent the last week or so traveling, spending time with family, and of course indulging in that delicious Thanksgiving meal is time to get back to basics especially as winter months approach where days are shorter with fewer hours of sunshine.  Are you getting enough Vitamin D in your diet?

Many recent studies show this essential vitamin to be low or deficient in many of us with chronic illnesses like diabetes, lupus, and of course Parkinson’s disease among others. In fact, as per Archives of Neurology Vitamin D is so compromised in PD patients that roughly 1/2 of the people with PD have  Vitamin D insufficient, while a 1/4 have show a clear deficiency.
[The Endocrine Society
 uses the following guidelines for vitamin D blood levels in adults and children:
Vitamin D deficiency-20ng/ml or less
Vitamin D insufficiency- 21-29ng/ml
Vitamin D sufficiency – 30ng/ml or greater (NL) ]

Thus, if your Vitamin D levels have not been checked recently by your health provider they should be; plus you should have vitamin supplement in your medicine cabinet. The reason for this is not only that most of us with chronic illnesses have a deficiency but even for those of us who are otherwise healthy can’t seem to get enough of it as per recent studies despite being present in many ordinary foods we eat. Some of the reasons for insufficiency despite adequate nutrition is small quantities in food and although we should be able to absorb what we need from the sun rays. It seems many of us at least in this country are not getting enough sunlight perhaps because we have become more indoor and sedentary and when we are outdoors we wear more UV light protective clothing and make up.

So why is Vitamin D such a big deal?

Well I think we all know about its relationship to calcium and strong bones. When its deficient we are more prone to fractures a common problem with PD especially since we are more likely to have falls as disease advances.

Vitamin D is also a key to boosting our immune system and reducing inflammation – this may be one of the crucial treatments in helping those with LLRK2 gene carriers to help with PD symptoms ( still not fully understood role of inflammation in this subtype). another reason to take Vitamin D supplement is the studies which suggest a decrease in blood sugars ( in type 2 diabetics) in those with higher Vitamin D levels. As I have mentioned before, people with PD are more likely to develop insulin resistance due to dopamine replacement which can potentially lead to diabetes; especially in those of us who are already at risk. Thus having a higher level of Vitamin D in your system can lower your risk for developing type 2 diabetes. Furthermore, Vitamin D is also important in memory and fatigue but it does not stop there. Early reports have suggested problems in kidney, nerves, and eyes with low levels.

If you have had gastric bypass, inflammatory bowel disease, have dark skin, are obese, older, or have limited exposure to sun are at an even higher risk of having severe deficiency when compounded with PD.

According to the USDA fatty fish ( e.g. salmon) is a top source as well as eggs (yolks), and liver (beef). many of us believe that milk is an excellent source of calcium although vitamin D fortified in order to get dietary needs met you would have to consume 13 cups daily.

  • The Endocrine Society- recommends 1,500 IU while NIH suggests 600 IU –
  • Look for supplements labeled D3- same as body makes
  • Eat a fat source such as peanut butter, avocado, or egg with supplement to better absorb the vitamin
  • Try app-dminder.ontometrics.com to gauge how much vitamin D you need

However, in the end the best way to determine how much supplement you need is by talking to your physician first.

 

Sources:

“The Need for Vitamin D”: Diabetic Living. (winter 2016), 56-57.

Devere Ronald, MD FAAN, “Cognitive Consequences of Vitamin D Deficiency”, Practical Neurology,Vol. 13, No.1,January/February2014.

“Low Vitamin D levels Associated with Parkinson’s Disease’, Parkinson’s Disease Foundation News & Review, winter 2009