Curcumin for clinical and endoscopic remission in ulcerative colitis

To the Editor: Curcumin, or diferuloylmethane, is an active principle of the herb Curcuma longa (turmeric) and is commonly used as a seasoning agent in curry.1 Its anti-inflammatory properties have lead to its use by patients with inflammatory bowel disease (IBD). We report the case of a patient with ulcerative colitis (UC) refractory to mesalamine and multiple courses of steroids who achieved clinical and endoscopic remission with oral curcumin. A 60-year-old lady with a 17-year history of left-sided UC and enteropathic arthropathy was seen for management of persistently active colitis in December 2009. She had previously failed multiple mesalamine preparations (oral and rectal), sulfasalazine, and steroid enemas, and had required multiple courses of steroids for disease exacerbations. She refused azathioprine/6-mercaptopurine and anti-tumor necrosis factor (TNF) treatment because of concerns regarding possible side effects. Clinical and endoscopic (Fig. 1, left) evaluation both confirmed active colitis. Treatment with 40 mg per day of prednisone was commenced, with a taper of 10 mg per week. In addition, she commenced curcumin 500 mg per day. On a return visit in January 2010 she was down to two bowel motions per day without blood, feeling well, and off steroids. She remained in clinical remission at further clinic evaluations in April, July, and December 2010. A colonoscopy performed in September 2010 (Fig. 1, right) showed no ulceration and biopsies consistent with chronic inactive UC. Sigmoid colon in December 2009 (left) and September 2010 (right). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] The mechanism of action for curcumin in treating colitis is not fully understood. Its molecular targets include transcription factors, growth factors, and growth factor receptors, enzymes, cytokines, and genes regulating cell proliferation and apoptosis.1 Mouse studies suggest curcumin has a significant inhibitory effect on inducible nitric oxide synthase (iNOS) and nuclear factor kappa B (NF-κB)2 and thus resembles sulfasalazine in terms of mechanism of action. The protective effects of curcumin against colitis in mice appear to be limited to a Th2-driven phenotype and are not replicated in Th1/Th17-derived colitis.3 Similarly, curcumin has no effect in treating colitis in interleukin (IL)-10 knockout mice,4 suggesting its therapeutic benefit may be more applicable to UC than to Crohn's disease (CD). Clinical data for CD are sparse,5 but a 2008 randomized controlled clinical trial in UC6 showed improved clinical and endoscopic remission rates for patients on curcumin with mesalamine/sulfasalazine compared to mesalamine/sulfasalazine alone. The study design had some weaknesses7 and a larger randomized study is desirable to determine which patient subgroups are most likely to derive benefit. Nonetheless, curcumin is safe, even at high doses,1 is well tolerated and, as was the case for this patient, may represent a viable treatment alternative or adjunctive therapy in the chronic management of UC.