Your Questions Answered by Dr. William Chamberlin:
How long does it take before I notice improvement after first starting AMAT?
The time it takes to appreciate a clinical response varies considerably depending on the extent of the disease and variables that are unknown to me. I tell patients that they may feel worse for a few weeks to a month. I warn them about a “flu-like illness” where they experience high fevers and generally feel lousy. Without truly knowing, I attribute this response to an “immune reconstitution syndrome” whereby the immune system begins to battle the infection. The major clinical symptoms are abdominal pain, diarrhea, fatigue and a decrease in the overall sense of well-being.
Improvement in these parameters may take months, but some patients start to feel better within a week or two. If there is no improvement after 6 months, I generally say that they are not responding.
What are the side effects I should expect when I start AMAT?
Which side effects would require me to discontinue AMAT?
What are the risks of AMAT?
Are there any tests or blood work I should have done prior to starting AMAT?
You should have a Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) as part of your initial evaluation. Nobody knows the optimum drug regimen against MAP. My standard regimen includes clarithromycin, rifampin and levofloxicin. The RedHill Study uses clarithromycin, Rifabutin and Clofazimine. Other combinations of drugs chosen for their efficacy against non-tuberculosis mycobacteria will probably work and have been used.
Each of these drugs carry the risk of side effects, and while severe side effects are rare, it would be prudent to have your prescribing doctor order a CBC and CMP after 3 weeks and then every 3 months to guard against effects on the bone marrow and liver. In rare cases, the interaction between clarithromycin and levofloxicin can cause cardiac arrhythmia. If you have a previously existing heart condition, you should discuss this risk with your doctor. Around two weeks after starting AMAT, I would advise having an EKG test to rule out arrhythmia. This should be repeated once a year.
I've heard some doctors start all of the medication at full strength on the first day, and some start with lower doses and gradually increase over time to the full dose. What are the benefits and drawbacks to each method?
What is the difference between Rifabutin and rifampin, and which is better for AMAT?
Rifampin and Rifabutin are related drugs in the same family. A major difference is the cost. Rifampin is a generic which is generally cheaper. Rifabutin may or may not be more effective against M. paratuberculosis in-vivo and it may be more prone to adverse reactions.
The standard dosage for adults is:
Rifampin is 300 mg. twice a day. (600 mg. daily)
Rifabutin is 150 mg. twice a day. (300 mg. daily)
My doctor told me this therapy isn't approved and I shouldn't consider it. Is AMAT an effective treatment for Crohn's disease?
Many doctors will be wary of AMAT since it is currently not an FDA approved treatment pathway for Crohn’s disease. Large scale studies are being done now to acquire this certification. However, there is a 20 year body of peer reviewed research which indicates that AMAT is as effective as other Crohn’s therapies in inducing remission. Additionally, all of the medications used for AMAT are antibiotics that are FDA approved. The doctors who hesitate to prescribe AMAT are generally concerned about medical malpractice liability issues, and have not read the body of research advocating AMAT for Crohn’s disease patients.
Your doctor also may have heard of the Selby study, which concluded that AMAT was not effective in Crohn’s disease patients. That study had many flaws, but the data in fact showed that the regimen of clarithromycin, Rifabutin and Clofazimine was beneficial in treating Crohn’s disease. Straight-up Intention-to-treat analysis of the raw data showed that AMAT was beneficial. In fact, the percentages of subjects responding to AMAT in the Australian study were higher than the percentages responding to Infliximab in the original studies used to get Infliximab approved.
Current dogma is based on poor science and is internally inconsistent. Current dogma says that anti-mycobacterial antibiotics are not effective, but the same dogma says that Ciprofloxacin and Metronidazole may work and encourages their use. These two drugs are both great anti-mycobacterial drugs. The inconsistencies are ignored rather than addressed. For a more thorough analysis of the Selby study, please see the Treatment of Crohn’s via Anti-MAP on this site.
I tell patients that AMAT is effective in some patients but not everyone. The same is true when treating drug resistant Tuberculosis. Every patient becomes their own “therapeutic trial.” This is also true of all other therapies recommended for treating Crohn’s disease.
Help! My doctor won't prescribe AMAT. What do I do?
How long do I take AMAT?
This question is yet to be resolved. John Hermon-Taylor’s work may provide the tools required to follow a bacterial response to therapy. How long do you stay on Humira? The answer is “until it stops working.”
I usually suggest patients continue for 3-6 months. If there is no improvement in clinical symptoms then I say that there is no evidence that it is working. If there is clinical improvement then I recommend full dose therapy for 2-3 years. At that point we feel our way forward. I simply do not know how long to treat. One man has been on AMAT for 17 years, and refuses to discontinue therapy because he does not want to risk relapse. You should discuss the benefits and risks of discontinuing therapy with your prescribing doctor.
Will my Crohn's come back if I stop AMAT?
What is the remission rate of AMAT?
Does AMAT work for ulcerative colitis?
Is AMAT better than the Anti-TNF medications like Remicade or Humira?
I've been on AMAT for a couple of months and I feel great, but I still have loose bowel movements. Does this mean AMAT is not working?
No. Success of AMAT is best judged by how the patient feels overall. Loose bowel movements are only part of that analysis. Certainly, the goal is to have a full remission of all Crohn’s symptoms, but some patients continue to experience loose bowel movements depending on their individual bodies or because it takes time to heal long term damage. If you otherwise notice an improvement of symptoms, I would be less concerned about loose stools.
One risk of AMAT is infection with C. Difficile. This causes severe, watery diarrhea and greater than normal gut pain. If you notice these type of symptoms, it is best to contact your prescribing physician or seek immediate medical attention.
I tried AMAT for 6 months and I don't feel any better. Does this therapy work for all Crohn's patients?
Can AMAT be used to treat diseases other than Crohn's disease?
There is a trial by RedHill Biopharma testing AMAT in multiple sclerosis patients. Other classic autoimmune diseases may be shown to have a mycobacterial cause, and AMAT may be successful for those patients as well. We will see.
The mycobacteria we believe is responsible for some cases of Crohn’s disease has also been cultured from patients with other autoimmune diseases. The research is in the infancy stages for diseases other than Crohn’s disease, but new trials can be expected in the future. Obviously, I do not like the term “autoimmune diseases.” In some cases the term may be accurate, but this term was indiscriminately applied to any chronic inflammatory disease of unknown cause. Many of these disorders may in fact be due to an underlying infection that has not yet been identified.