November 26, 2014

What are the risks of Fecal Transplants for treating Ulcerative Colitis?

Question: When I first mentioned fecal transplants to  few close friends and family it created quite a stir. Beyond just the “ick” factor, a doctor talked about the risks of infectious diseases and a biologist expressed concern over changing the gut flora in the body, given all of the factors it is involved in. However I am facing surgery or continued treatment with Prednisone and possibly Remicade if I continue to have frequent, severe flares of Colitis. I know the risks of Colitis and drug side-effects, so what are the actual risks from fecal transplants when taking proper precautions?

Answer: Unfortunately there is considerable misinformation and speculation about fecal transplants, in part because of the “ick” factor and long-standing FDA regulations there are relatively few doctors who are very experienced with these. Even when they are involved doctors have to walk a fine line with the FDA and liability concerns from hospitals, which may limit their role to largely being an advisor and a person who can prescribe tests and medications, while leaving you to do all of the fecal transplants yourself or at least any ones past the first one using a colonoscope.

For these reasons, patients have to be their own advocates and be informed and actively involved in all decision-making when it comes to deciding if this is a treatment option for you and how to do it safely and effectively. While there is a risk of infectious diseases from stool or even blood, these can largely be mitigated by testing of donors. There are several established protocols by doctors of illness to test for. These can include illness that could be transmitted by blood including HIV, Epstein-Barr, Syphillis and Hepatitis and for stool tests for several different known pathogens including Clostridium Difficile, Giardia, Cryptosporidium and more. With a donor questionnaire (I include one in my book which describes how to use fecal transplants to treat Ulcerative Colitis) you can identify which people are most likely to be at risk for having these illnesses. Questions include a would-be donor’s medical history, travel and lifestyle. Then tests can be run to screen for these illness with a high degree of accuracy.

Of course even with donor screening there is no way to completely eliminate all risks. However with the possible exception of HIV, which despite much publicity is still very rare and largely limited to certain demographic groups, none of the illnesses you could hypothetically contract are fatal or incurable.  However there are no known cases where a receipient has contracted any of the illnesses that could be transmitted by blood, which is usually not in the stool of a person who is healthy anyway.  I have heard a few reports where someone receiving a fecal transplant has later tested positive for Clostridium Difficile even though the donor had been tested and did not have any symptoms. However this is rare and even if it does happen, the solution is just to find another donor.

Of course any risks have to be weighed against the significant impacts of the illnesses it is used to treat. Colitis caused by Clostridium Difficile bacteria often is not permanently cured by anti-biotics and can often be fatal, with over 14,00 deaths in the U.S. in the past year, including the father of a close friend of mine.  The risk-reward trade-off is very clear when it comes to c. diff, it could become a matter of life or death for a safe, effective solution that can work within a matter of days.

Ulcerative Colitis is a bit more of a complicated risk to calculate. While the illness itself rarely causes people to die, it also carries many significant health risks depending on which drug therapies are used and how severe the illness is for that person. In addition to the often debilitating impact on quality of life from Colitis, drug side effects can include Osteoperosis, diabetes, secondary infection and even rare forms of cancer just to name a few.  So the decision to pursue this is not necessarily life or death, however it could mean avoiding many chronic health problems caused by drug side effects and being able to avoid surgery and wear an ostomy bag or have a j-pouch which while manageable can also diminish quality of life.

Of the Known risks of using fecal transplants for Ulcerative Colitis here are a few: 

– There is a slight possibility, even with donor screening that you could get some form of c. diff bacteria. The solution in this even would be anti-biotics and / or finding another donor to try them again.

– FMT could trigger a flare-up of symptoms including blood in stool. This could be because of some bacteria dying off. It could also be because the gut barrier, the colon walls, are damaged to the point where any change in bacteria can trigger inflammation due to increased sensitivity. This is why drugs to limit inflammation could be very effective, especially in more severe, active cases of Ulcerative Colitis. In my case I dealt with this by continuing fecal transplants while taking Prednisone and then added on a cocktail of drugs including Bupropion, Doxepin and mesalamine. Yes, it could trigger a flare, but you will get past it. However I would warn people who are dogmatically against using drugs to treat their colitis to reconsider, since any use of drugs along with FMT would be of relatively short duration in exchange for it working long term without needing any drugs.

– The problem might be more complicated than just an overgrowth of one particular strain of bacteria as in infectious Colitis like c. diff. It might be that establishing the right balance of bacteria is what is necessary, while the native bacterial colony attempts to re-establish itself. This could mean that the fecal transplants have to persist for an extended period of time to keep re-enforcing a mix of bacteria which will lead to sustained remission in the future. The battle of bacteria could lead to inflammation or just gas and diarrhea. However these symptoms might not be any worse than the illness. This is where pre-treating with a course of anti-biotics before fecal transplants might be helpful.

– There could be changes in metabolism. In other words stool from a fat person could make you fat or vice versa. This is where finding a donor who is in all around good physical condition or in general shares a similar body type could be helpful.

– There are potentially unknown systemic effects to the body in terms of psychology, metabolism or complicated syndromes. However thus far none have been identified, however picking a donor who is as healthy as possible and free of almost any possible illness is a key consideration.

Conclusions 

Of course there are some risks which have to be weighed against the rewards. Is it worth these manageable risks and some short term inconvenience to have a life free of Ulcerative Colitis, free of drugs and their side effects and also the ability to eat whatever you want without paying the price for it? Perhaps this sounds too good to be true if you are dealing with a rough stretch of this illness, however I can say that for me and others who are now free of any symptoms of this illness that it has totally been worth it as it has worked better than even my highest hopes.