Crohn’s disease is a chronic illness with episodic flair ups, involving excessive inflammatory immune system signaling. Excessive tumor necrosis factor signaling is one such problem.

The excessive inflammatory signaling affects not only the intestines but the entire body. For example, it can cause depression and other mental illnesses. It can stimulate sympathetic nervous system activity, causing insomnia, stress, anxiety, etc. It can cause adrenal dysregulation – resulting in impaired production of adrenal cortex hormones in response to stress. It can cause arthritis and other inflammatory illnesses. It can change numerous functions in the nervous system and endocrine system.

Treatment choice is a problem. If possible, I would prefer avoiding treatment which globally impairs metabolism and would choose more targeted treatments.

Azathioprine, for example, is particularly toxic. It’s primary mechanism of action is to prevent DNA and RNA synthesis. This reduces white blood cell production and thus suppresses immune system signaling. But it also causes problems in the rest of the body’s cells. Since RNA synthesis is impaired – protein synthesis, the production of other signals, response to other hormones, neurotransmitters, etc. etc. are impaired. This in turn can cause other physical health problems, endocrine problems, mood problems, etc. with cancer as the ultimate outcome. Yes, if possible, I would avoid its use.

Medications that specifically target inflammatory signals are going to be safer in that they are less likely to cause problems in other systems of the body. Thus, medications that target tumor necrosis factor signaling – such as Humira – are safer. Asacol (Mesalamine), which inhibits leukotriene signaling is safer.

Low dose Naltrexone is an alternative-medicine option in treating Croh’s Disease – in helping reduce inflammatory signaling. This is a particularly safe treatment. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Retrieve&list_uids=17222320

Nutrition usually needs to be optimize to help reduce inflammation. For example, omega-3 fatty acids may need to be added, foods with gluten may need to be avoided, fat soluble vitamin intake may need to be improved, etc. etc. Alternatives to simple carbohydrate intake need to be considered since simple sugars can increase inflammatory signaling.

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Effexor is an effective antidepressant. It works by increasing both serotonin and norepinephrine signaling. This is a problem, however, when with patients who already have excessive norepinephrine signaling since raising norepinephrine signaling further can also worsen their problems or later cause a crash. Excessive norepinephrine signaling, for example, can lead to anxiety, insomnia, and eventually increased inflammation. The combined increase in serotonin and norepinephrine may be useful in the short-term, but I worry about how stable the patient’s condition can be if I am exacerbating one of their signaling problems in the process. It is a double-edged sword. Some patients may need this treatment, but I have to be ready to adjust other signals to compensate.

This is a reason I prefer medications that have a single mechanism of action. I can more easily control the signaling process and reduce complications. For example, if I wanted to increase norepinephrine while increasing serotonin, I can simply add a stimulant to the treatment and can control dose – rather than have a one-size fits all treatment as with the combination medications.

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A problem in medicine is that many physicians, once they are aware that a person has a mental illness, will tend to blame every physical problem that a person has on the mental illness.

“It’s all in your head” they may think. Thus, they will end up missing the presence of an actual physical illness.

For example, when patients come to the emergency room with a panic attack complaining of chest pain, the physician may not realize that up to a quarter of these patients actually are having a heart attack and instead would blame the chest pain on the panic attack, missing the heart attack in the process.

One of my patients had congestive heart failure, but his physician thought it was all in his head. Another had a pus filling half of her lungs but the internist also thought it was all in the patient’s head.

A group of psychiatrists and internists even missed severe hypothyroidism in a patient with delirium who they thought had psychosis instead. Delirium usually indicates the presence of a physical problem but if mistaken for psychosis, the physical problem can be overlooked. I was called to examine the patient when she had a prolonged stay in the hospital and was non-responsive to psychiatric treatment. It was easy to see what was missed.

Perhaps it is human nature. But knowing or thinking that a person has a mental illness can seriously impair a physician’s thinking, blinding them to what may be physically occurring, unless they realize this and have the skills to take appropriate measures to avoid this blindspot. This is a very common occurrence – even with some psychiatrists.

It is so common that many of my patients, once they realize this is occurring, learn to avoid discussion of their mental illness with their primary care provider or other physician so that they can get a more accurate assessment of their physical health problems. They focus on discussing the physical manifestation of their illness – e.g. fatigue, pain, weakness, etc., avoiding words such as anxiety, depression, stress, etc. They would approach the physician in as calm a manner as they can, avoiding being demanding or tension or other signs of stress, that can get them labeled as “mental”.

When I speak to internists, etc., I often help their thought process by avoiding the psychological issues, and focus on the physical manifestations of the problem. It is interesting to see how much faster and more accurately they hone into the problem when mental problems are avoided on initial discussion.

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Given the large overlap in functions, it can be difficult to assess for deficiencies in many hormones, much less determine treatment dosing, without adequate lab testing. Thus, one can’t assume one has a testosterone deficiency or growth hormone deficiency when one hasn’t done lab testing.

Thyroid hormone deficiency or inadequate thyroid signaling, is one of the exceptions in that it can be observed on physical exam. However, at which level of signaling does the problem exist is more difficult to determine. For example, is thyroid signaling impaired by impaired production of thyroid hormone, by impaired transport into cells, by impaired cofactors such as vitamin A and iron and the b-vitamins, etc. etc. Lab testing helps clarify the issues. Otherwise, adding thyroid hormone would still be a clinical trial or trial and error treatment.

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When a person has multiple health problems, a systemic assessment needs to be done to help determine how everything is interacting to cause the various problems and to determine treatment – which will generally be complicated. As such, ideally, it is important to assess nervous system, endocrine system, immune system, and metabolic/nutritional function.

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Hydrocortisone alone is an incomplete treatment, which also can cause deficiencies in the other adrenal hormones when given alone. Many people can tolerate these problems (e.g. reductions in progesterone, DHEA, estrogen, testosterone, pregnenolone, etc.). But many cannot and need replacement of one or more of these other hormones to have a more complete and adverse-effect free treatment. The minimum would be to pair hydrocortisone with an androgen (such as DHEA), if tolerated – which in some women and men is not.

Have you had vitamin D levels checked? Deficiency can cause depression. Also, sufficient levels help to control blood sugar I’m thinking with you being in GB and bedridden you have not gotten much in the way of sunshine? What about your ferritin levels? B12? magnesium? Definitely hormone deficiencies will contribute to your problems- but nutritional deficiencies also need to be addressed. Also, Crohns disease certainly makes it hard to absorb your nutrients and probably has a huge impact on your absorption of hc- you are probably only getting a fraction of what you are taking. Have you ever tried a gluten free diet? Just some thoughts…

The dietary issues can definitely CAUSE increased hormonal difficulties. Gluten intolerance and celiac actually can cause thyroid problems and adrenal issues- fixing these things can alleviate some of these problems without having to take the supplemental hormone. Dr Mariano talks about adequate iron to help the adrenals as well.

I was wondering about you consulting with Dr. Peatfield? He is in the UK and does email consultations. His email address is DrBarryPeatfield@AOL.com. He is very nice and knows a lot about thyroid and adrenals etc. Maybe you could see him as well.

Funny (not really) but my low cortisol issues have always been worse at night and I have to take isocort during the night to sleep well-

Good luck to you! I have been following your post on the Addison’s site.