Is there strong evidence for using Boswellia (boswellia serrata) in treating low-grade ulcerative colitis?

Evidence for Boswellia in Low-Grade Ulcerative Colitis

The American Gastroenterological Association recommends against using Boswellia serrata for ulcerative colitis, and you should not prescribe it for this indication. 1, 2

Guideline Recommendations

The AGA explicitly advises against Boswellia serrata treatment for inflammatory bowel conditions based on their systematic review of the evidence 1. While their formal recommendation addresses microscopic colitis specifically, the AGA makes no recommendation for Boswellia in ulcerative colitis guidelines, effectively excluding it from the treatment algorithm 1. The rationale for recommending against its use includes:

• Uncertain benefit-risk balance: A single randomized controlled trial showed only 44% of patients treated with Boswellia serrata improved clinically compared to 27% in the placebo arm, with no statistically significant difference 1
• No quality of life improvement: The trial demonstrated no difference in quality of life between treatment and placebo groups 1
• Higher adverse event rates: Patients receiving Boswellia experienced more frequent adverse events than placebo 1
• Lack of standardization: Numerous Boswellia products are available without standardized formulations, making consistent dosing and quality control impossible 1, 2

Evidence Quality Assessment

The evidence supporting Boswellia for any form of colitis is low quality at best 1, 3. The Cochrane systematic review on collagenous colitis found that one study of Boswellia serrata extract (three 400 mg/day capsules for 8 weeks) showed a clinical response in 44% versus 27% with placebo, but this difference was not statistically significant (RR 1.64,95% CI 0.60 to 4.49) 3.

Contradictory Evidence and Important Caveats

Two older studies from 1997 and 2001 showed positive results, but these have significant methodological limitations:

• A 1997 study reported 82% remission with Boswellia versus 75% with sulfasalazine in ulcerative colitis grades II-III 4
• A 2001 study showed 14 of 20 patients (70%) achieved remission with Boswellia versus 4 of 10 (40%) with sulfasalazine in chronic colitis 5

However, these studies are not considered reliable because they:

• Lack proper blinding and randomization details
• Have small sample sizes
• Were conducted over 20 years ago without replication
• Are contradicted by more recent systematic reviews 3, 6

Critical safety concern: Animal studies demonstrate that Boswellia may be hepatotoxic at higher doses, causing pronounced hepatomegaly, steatosis, and dysregulation of lipid metabolism genes 7. The same research showed Boswellia was completely ineffective in ameliorating colitis in mouse models and actually increased NF-κB activity in intestinal epithelial cells 7.

What You Should Use Instead

For mild-to-moderate ulcerative colitis, the evidence-based treatment algorithm is 1:

1. First-line: Standard-dose mesalamine (2-3 g/day) or high-dose mesalamine (>3 g/day) 1
2. For proctitis/proctosigmoiditis: Mesalamine enemas or suppositories are superior to oral therapy 1
3. If refractory to 5-ASA: Add oral prednisone or budesonide MMX 1, 8
4. Budesonide should not be used for long-term maintenance in ulcerative colitis 8

The evidence for mesalamine is high quality with clear dose-response relationships: high-dose mesalamine (>3g/day) reduces failure to induce remission by 225 fewer per 1,000 patients compared to placebo (RR 0.75,95% CI 0.65 to 0.86) 1.