Therapy for Increased Intestinal Permeability (“4 R” approach originated by the field of naturopathy)

This approach to restoring a healthy gut-immune exercises can induce relaxation barrier includes four steps: 1) removing mucosal and proper acidity in the GI tract.) irritants, 2) replacing agents for digestive – Meditation for Health and support, 3) reinoculating with friendly bacteria Happiness (patient version) and the foods they need to grow, and 4) – Loving-Kindness Meditation repairing the mucosal lining. 2. Replace agents for digestive support. (This step may not be necessary). 1. Remove mucosal irritants such as allergenic foods, alcohol, medications • Consider a short course of pancreatic and stress. enzymes and in some cases Betaine HCL if low acidity.

• Recommend an elimination diet o If needed, consider prescribing a o Start with (wheat) and dairy product called Pancrease MT 10, 1-2 o See handout on “Elimination Diet” capsules before each meal for a short • Remove medications if possible period of time until the digestive o Long-term antibiotics process improves. The patient should o Non-steroidal anti-inflammatory not need these enzymes for a long medications (Ibuprofen, Naproxen, etc.) period of time (more than 3 months). o Prednisone They are used just until the GI o Prolonged use of acid-suppressing mucosa has time to return to optimal drugs (proton pump inhibitors, H2 state of health. blockers) o If more acid is needed, recommend • Reduce simple sugars, refined Betaine HCL for a short period of carbohydrates, saturated fat and red time until symptoms resolve. meat to adopt a diet that reduces – This commonly comes in a dose inflammation. of 10 grains (648 mg). The o See handout on Glycemic Index patient can use 1-3 tablets with o See handout on Anti-Inflammatory Diet each meal. Direct the patient to (clinician version) (patient version) start with one and increase to 3. • Treat possible pathogens (c. difficile If there is any burning sensation colitis, H. Pylori, parasites, etc.) in the stomach, the dose should • Reduce perception of stress and be decreased by one pill. As the stress triggers stomach develops the ability to o Suggest a Mindfulness Based Stress create its own acid, a warm Reduction course feeling may develop that would o Refer patients to the following signal the need to taper off this handouts: supplement. This supplement – Breathing Exercise. (Gastric should not be used for longer acid secreted is stimulated by the than one month. vagus nerve. Deep breathing

PEARLS FOR CLINICIANS University of Wisconsin Integrative Medicine www.fammed.wisc.edu/integrative Therapy for Increased Intestinal Permeability (“4 R” approach originated by the field of naturopathy)

3. Reinoculate with friendly bacteria o Psyllium Husks (Metamucil) One tsp. and the foods they need to grow. before meals in 8-10 oz of water or • Consider juice. supplementation, including o Guar Gum. This is less “gritty” but Lactobacilli and Bifidobacteria more expensive than psyllium. One tsp. before meals in 8-10 oz of water or o juice. These “good” bacteria in the colon o Oat bran/Oatmeal. Consume as cereal produce lactic acid and hydrogen each morning. peroxide that keeps the growth of o Ground Flax Seed, one tsp. over food “bad” bacteria in check. They have or in water or juice before each meal. been found to improve diarrhea in those taking antibiotics and have been • Direct patient to drink adequate amounts found to be helpful in reducing the (2 liters) of filtered water daily. growth of yeast. They also help • The following supplements have been support the integrity of the lining of the found to help the lining of the intestinal intestines. Products to consider: wall repair itself. Consider supplementing Floragen 3 which includes three with them for one month: strains of bacteria (made in Madison, o Antioxidants such as vitamins C, E and WI) and Culturelle which contains A, selenium, and carotenoids. GG. Recommend a daily multi-vitamin. • Consider fructooligosaccharides and o Zinc 25-30 mg daily inulin to enhance growth of friendly flora o Omega-3 fatty acids (EPA/DHA) in the form of fish oil. Recommend 2 gms o Pre-biotics daily. Short chain sugars called o L- Powder. This amino acid fructooligosaccharides (FOS) have is an important nutrient for intestinal been found to promote the growth of repair. The dose is 5 gms of powder friendly bacteria in the gut. Foods that twice daily for one month. Sometimes contain them include bananas, the dose needs to be increased to 20 Jerusalem artichoke, onions, gms of powder in liquid twice daily. asparagus and garlic. o If the patient is constipated, consider a short course of aloe vera. 5-60 drops of 4. Repair mucosal lining. an aloe tincture (1:10, 50% alcohol) • Regular aerobic exercise helps maintain can be used daily for one month. regular motility and reduces the stress- induced enzymes that can disrupt the GI barrier. Encourage daily movement and exercise.

• Patients should include soluble and insoluble fiber. This helps develop This handout was created by David Rakel, MD, healthy mucous and maintains regular Asst. Prof. and Director of the Integrative transit time in the gut. Adequate intake of Medicine Program, Dept. of Family Medicine, whole fruits and vegetables is important. University of Wisconsin-Madison. Good sources of soluble (viscous) fiber include: Date created: July 2008

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