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Thomassen RA, Luque V, Assa A, Borrelli O, Broekaert I, Dolinsek J, Martin-de-Carpi J, Mas E, Miele E, Norsa L, Ribes-Koninckx C, Saccomani MD, Thomson M, Tzivinikos C, Verduci E, Bronsky J, Haiden N, Köglmeier J, de Koning B, Benninga MA. An ESPGHAN Position Paper on the Use of Low-FODMAP Diet in Pediatric Gastroenterology. J Pediatr Gastroenterol Nutr 2022; 75:356-368. [PMID: 35706093 DOI: 10.1097/mpg.0000000000003526] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Excluding oligo-, di-, monosaccharides and polyols (FODMAPs) from the diet is increasingly being used to treat children with gastrointestinal complaints. The aim of this position paper is to review the available evidence on the safety and efficacy of its use in children and provide expert guidance regarding practical aspects in case its use is considered . Members of the Gastroenterology Committee, the Nutrition Committee and the Allied Health Professionals Committee of the European Society for Pediatric Gastroenterology Hepatology and Nutrition contributed to this position paper. Clinical questions regarding initiation, introduction, duration, weaning, monitoring, professional guidance, safety and risks of the diet are addressed. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. The systematic literature search revealed that the low-FODMAP diet has not been comprehensively studied in children. Indications and contraindications of the use of the diet in different pediatric gastroenterological conditions are discussed and practical recommendations are formulated. There is scarce evidence to support the use of a low-FODMAP diet in children with Irritable Bowel Syndrome and no evidence to recommend its use in other gastrointestinal diseases and complaints in children. Awareness of how and when to use the diet is crucial, as a restrictive diet may impact nutritional adequacy and/or promote distorted eating in vulnerable subjects. The present article provides practical safety tips to be applied when the low-FODMAP diet is considered in children.
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Affiliation(s)
- R A Thomassen
- From the Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - V Luque
- Paediatric Nutrition and Development Research Unit, Serra Hunter Fellow, Universitat Rovira i Virgili-IISPV, Spain
| | - A Assa
- The Juliet Keidan institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - O Borrelli
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - I Broekaert
- the Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - J Dolinsek
- the Department of Paediatrics, University Medical Centre Maribor, Maribor, Slovenia
| | - J Martin-de-Carpi
- the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - E Mas
- Service de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, Toulouse, France; IRSD, Université de Toulouse, INSERM, INRAE, ENVT, UPS, Toulouse, France
| | - E Miele
- the Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Naples, Italy
| | - L Norsa
- the Department of Paediatric Hepatology, Gastroenterology and Transplantation ASST Papa Giovanni XXIII, Bergamo, Italy
| | - C Ribes-Koninckx
- Paediatric Gastroenterology, Hepatology & Nutrition, La Fe University Hospital & Instituto de Investigacion Sanitaria La FE, Valencia, Spain
| | - M Deganello Saccomani
- the Department of Paediatrics, Woman's & Child's University Hospital of Verona, Italy
| | - M Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, UKthe
| | - C Tzivinikos
- Department of Paediatric Gastroenterology, Al Jalila Children's Specialty Hospital, Mohammed Bin Rashid University Of Medicine and Health Sciences, Dubai, UAE
| | - E Verduci
- the Department of Pediatrics, Ospedale dei Bambini Vittore Buzzi, University of Milan, Italy
| | - J Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - N Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - J Köglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London, UKthe
| | - B de Koning
- Department of pediatric gastro-enterology, ErasmusMC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M A Benninga
- the Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands
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Metyas S, Chen C, Joseph M, Hanna N, Basta J, Khalil A. Subcategories of Fibromyalgia: A New Concept. Curr Rheumatol Rev 2022; 18:18-25. [PMID: 35220935 DOI: 10.2174/2666255815666220225103234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/03/2021] [Accepted: 11/24/2021] [Indexed: 02/08/2023]
Abstract
Fibromyalgia has previously been categorized as primary, secondary, and juvenile fibromyalgia. However, these definitions do not adequately explain the etiopathology of disease, nor do they help direct new specific therapies. Herein, we review the previously known categorizations of fibromyalgia. Based on common patient characteristics and previously studied pathophysiologies, we propose new subcategorizations of fibromyalgia that we have self-narrated, including hormonal fibromyalgia, neuroendocrine fibromyalgia, psychologic fibromyalgia, inflammatory fibromyalgia, and lastly, neuropathic fibromyalgia. Future research needs to be done to verify, add to, and fully describe these self-narrated categories of fibromyalgia that we have proposed.
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Affiliation(s)
- Samy Metyas
- Covina Arthritis Clinic, Covina, California, CA, USA
| | | | - Marina Joseph
- Covina Arthritis Clinic, Covina, California, CA, USA
| | | | - Joseph Basta
- Covina Arthritis Clinic, Covina, California, CA, USA
| | - Andrew Khalil
- Covina Arthritis Clinic, Covina, California, CA, USA
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Li Y, Peng S, Liang F, Liu S, Li J. Effectiveness of acupuncture for irritable bowel syndrome: Protocol for a scoping review of systematic reviews and meta-analyses. Medicine (Baltimore) 2022; 101:e29218. [PMID: 35866802 PMCID: PMC9302279 DOI: 10.1097/md.0000000000029218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a common functional bowel disorder. Many systematic reviews/meta-analyses indicate that acupuncture and related therapies are effective for IBS. However, the robustness of the results in the systematic reviews and meta-analyses has not been evaluated. This scoping review aims to ascertain the credibility of current evidence of acupuncture therapy for IBS, to provide clinical research investigators with reliable information. METHODS Searches of China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), China Biology Medicine disc (CBMdisc), and Wanfang Database since the establishment of the database to February 2022. Study selection and data extraction will be conducted by 2 reviewers, and the quality will be assessed by 2 trained reviewers. We will use Assessment of Multiple Systematic Reviews-2 (AMSTAR2) for methodological quality assessment, Preferred Reporting Items for Systematic Reviews and Meta-Analyses for report quality assessment, Grading of Recommendations, Assessment, Development, and Evaluation for the quality of evidence assessment, and the Risk of Bias in Systematic Reviews for the bias assessment. RESULTS The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER INPLASY202210117. CONCLUSION This scoping review will provide comprehensive evidence of acupuncture for patients with irritable bowel syndrome. ETHICS AND DISSEMINATION This scoping review does not require ethical approval as it is a secondary assessment of available literature.
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Affiliation(s)
- Yachen Li
- College of Acupuncture and Orthopedics, Hubei University of Chinese Medicine, Wuhan, China
| | - Sike Peng
- College of Acupuncture and Orthopedics, Hubei University of Chinese Medicine, Wuhan, China
| | - Fangyuan Liang
- College of Acupuncture and Orthopedics, Hubei University of Chinese Medicine, Wuhan, China
| | - Suzhen Liu
- College of Acupuncture and Orthopedics, Hubei University of Chinese Medicine, Wuhan, China
| | - Jia Li
- College of Acupuncture and Orthopedics, Hubei University of Chinese Medicine, Wuhan, China
- *Correspondence: Jia Li, Hubei University of Chinese Medicine, No. 4 Garden Hill, Liangdao Street, Wuchang District, Wuhan, Hubei 430061, China (e-mail: )
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Moshiree B, Heidelbaugh JJ, Sayuk GS. A Narrative Review of Irritable Bowel Syndrome with Diarrhea: A Primer for Primary Care Providers. Adv Ther 2022; 39:4003-4020. [PMID: 35869354 PMCID: PMC9402521 DOI: 10.1007/s12325-022-02224-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/14/2022] [Indexed: 12/09/2022]
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Rexwinkel R, Vlieger AM, Saps M, Tabbers MM, Benninga MA. A therapeutic guide on pediatric irritable bowel syndrome and functional abdominal pain-not otherwise specified. Eur J Pediatr 2022; 181:2603-2617. [PMID: 35460383 PMCID: PMC9192445 DOI: 10.1007/s00431-022-04459-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 12/14/2022]
Abstract
Disorders of the gut-brain interaction negatively impact quality of life and carry a substantial socioeconomic burden. Irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) are common functional abdominal pain disorders in childhood. The pathophysiology is not fully understood, and high-quality intervention trials and international guidelines are missing. Therefore, the management of these disorders remains challenging. This review aims to provide an up-to-date overview of therapeutic possibilities for pediatric IBS or FAP-NOS and recommends management strategies. To prevent unnecessary referrals and extensive costs, it is fundamental to make a positive diagnosis of IBS or FAP-NOS in children with chronic abdominal pain with only minimal investigations. A tailor-made approach for each patient, based on the accompanying physical and psychological symptoms, is proposed to date. CONCLUSION Shared decision-making including non-pharmacological and pharmacological interventions should be considered and discussed with the family. WHAT IS KNOWN • Irritable bowel syndrome and functional abdominal pain-not otherwise specified are common in childhood. • Although the number of treatment options has grown recently, managing these disorders can be challenging and unsatisfactory, and no evidence-based international management guidelines are available. WHAT IS NEW • We suggest using a stepwise individualized approach to management, where after first-line management, both non-pharmacological and pharmacological interventions should be discussed.
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Affiliation(s)
- Robyn Rexwinkel
- Emma Children's Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, Room C2-312, PO Box 22700, 1100 DD, Amsterdam, Netherlands.
| | - Arine M Vlieger
- Department of Pediatrics, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Miguel Saps
- Department of Pediatric Gastroenterology, University of Miami, Miami, FL, USA
| | - Merit M Tabbers
- Emma Children's Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, Room C2-312, PO Box 22700, 1100 DD, Amsterdam, Netherlands
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, Room C2-312, PO Box 22700, 1100 DD, Amsterdam, Netherlands
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The Role of Food in the Treatment of Bowel Disorders: Focus on Irritable Bowel Syndrome and Functional Constipation. Am J Gastroenterol 2022; 117:947-957. [PMID: 35435179 PMCID: PMC9169760 DOI: 10.14309/ajg.0000000000001767] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/29/2022] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome (IBS) and functional constipation (FC) are among the most common disorders of gut-brain interaction, affecting millions of individuals worldwide. Most patients with disorders of gut-brain interaction perceive food as a trigger for their gastrointestinal symptoms, and specific dietary manipulations/advice have now been recognized as a cornerstone therapeutic option for IBS and FC. We discuss in detail the 2 most common dietary interventions used for the management of IBS-general dietary advice based on the National Institute for Health and Care Excellence guidelines and a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). We summarize the literature around the possible mechanisms of FODMAP-mediated IBS pathophysiology, the current 3-step, top-down approach of administering a low FODMAP diet (LFD) (restriction phase, followed by reintroduction and personalization), the efficacy data of its restriction and personalization phases, and possible biomarkers for response to an LFD. We also summarize the limitations and challenges of an LFD along with the alternative approach to administering an LFD (e.g., bottom-up). Finally, we discuss the available efficacy data for fiber, other dietary interventions (e.g., Mediterranean diet, gluten-free diet, and holistic dietary interventions), and functional foods (e.g., kiwifruit, rhubarb, aloe, and prunes) in the management of IBS and FC.
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Xiao D, Zhang Y, Chen W, Xuan J, Chen Y. Cost-Effectiveness of Linaclotide Compared to Osmotic Laxatives in the Treatment of Irritable Bowel Syndrome with Constipation in China. Adv Ther 2022; 39:2971-2983. [PMID: 35488140 DOI: 10.1007/s12325-022-02161-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/06/2022] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Linaclotide, a selective agonist of guanylate cyclase C, was highly recommended for the treatment of irritable bowel syndrome with constipation (IBS-C). However, the cost-effectiveness of linaclotide in Chinese is not known, and this study aimed to assess the cost-effectiveness of linaclotide for patients with IBS-C. METHODS An economic evaluation was conducted with a Markov model from a societal perspective. The Markov model was structured to simulate the discontinuation and continuation of medication in IBS-C patients in clinical practice, as well as the revisit and non-visit of non-responding patients. The cycle of the model was 4 weeks, and the time horizon was 1 year. The efficacy data in the model was from the risk ratios obtained by the meta-analysis and the calculation of the response rate of the three medications. The utility, discontinuation rate of the medication, and revisit rate data were from published literature, while the cost data were obtained from experts' opinions and published literature. A series of sensitivity analyses was performed on parameters potentially having impact on the model outputs. RESULTS The QALYs (quality-adjusted life years) gained for 1-year treatment with linaclotide, polyethylene glycol, and lactulose were 0.821, 0.795, and 0.781, respectively. The corresponding total costs were CNY 7,721 (USD 1,120), CNY 8,797 (USD 1,276) and CNY 9,481 (USD 1,375). In both comparisons, linaclotide was dominant. Compared with polyethylene glycol and lactulose, the likelihood of linaclotide being cost-effective was 100% for both, using 1 times per capita GDP per QALY as willingness-to-pay threshold. CONCLUSIONS IBS-C seriously affects the quality of life of patients with IBS-C, and linaclotide can improve symptoms and quality of life at less cost.
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Affiliation(s)
- Dunming Xiao
- School of Public Health, Fudan University, Shanghai, 200032, China
- NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, 200032, China
| | - Yue Zhang
- Shanghai Centennial Scientific Co. Ltd, 702A, 388 Fenglin Road, Shanghai, 200032, China
| | - Wanxin Chen
- Health Economic Research Institute, Sun Yat-Sen University, 132 East Waihuan Road, Guangzhou University City, Guangzhou, 510006, China
| | - Jianwei Xuan
- Health Economic Research Institute, Sun Yat-Sen University, 132 East Waihuan Road, Guangzhou University City, Guangzhou, 510006, China.
| | - Yingyao Chen
- School of Public Health, Fudan University, Shanghai, 200032, China.
- NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, 200032, China.
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Goodoory VC, Craig OF, Gracie DJ, Black CJ, Ford AC. Prognosis of patients with Rome IV-defined versus physician-diagnosed irritable bowel syndrome: Longitudinal follow-up study. Neurogastroenterol Motil 2022; 34:e14282. [PMID: 34612560 DOI: 10.1111/nmo.14282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/19/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Little is known about the differences between patients diagnosed with irritable bowel syndrome (IBS) by a physician who meet the Rome IV criteria for IBS and those who do not. We conducted a longitudinal follow-up study examining this. METHODS We collected complete gastrointestinal, extraintestinal, and psychological symptom data from 577 consecutive adult patients with suspected IBS in a single UK gastroenterology clinic. We compared baseline characteristics between patients who met Rome IV criteria for IBS, and those who had IBS according to a physician's diagnosis but who did not meet Rome IV criteria, as well as examining whether meeting Rome IV criteria at baseline influenced evolution of symptoms under therapy. KEY RESULTS Of 455 patients diagnosed with IBS by a physician, 375 (82.4%) met Rome IV criteria and 80 (17.4%) did not. Those who met Rome IV criteria were more likely to report severe symptoms (67.6%, vs. 30.0%, p < 0.001) and that symptoms limited activities ≥50% of the time (63.0%, vs. 37.5%, p < 0.001). Patients with Rome IV IBS were more likely to have abnormal anxiety scores (50.8%, vs. 35.9%, p = 0.007) and higher levels of somatoform symptom-reporting (29.4%, vs. 12.5%, p < 0.001). Despite this, during longitudinal follow-up, there was no significant difference in mean number of appointments required subsequently, or IBS symptom severity. CONCLUSIONS AND INFERENCES Although patients who met the Rome IV criteria had more severe symptoms at baseline and were more likely to exhibit psychological comorbidity, they did not appear to have a worse prognosis than those with physician-diagnosed IBS.
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Affiliation(s)
- Vivek C Goodoory
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Orla F Craig
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - David J Gracie
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Christopher J Black
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
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Lee JH, Sung WS, Bak SB, Kim EJ, Kim YW. Evaluation of Xiaoyao-san for treatment of irritable bowel syndrome: A systematic review and meta-analysis of randomized controlled trials. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Black CJ, Staudacher HM, Ford AC. Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis. Gut 2022; 71:1117-1126. [PMID: 34376515 DOI: 10.1136/gutjnl-2021-325214] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/28/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) is recommended for irritable bowel syndrome (IBS), if general lifestyle and dietary advice fails. However, although the impact of a low FODMAP diet on individual IBS symptoms has been examined in some randomised controlled trials (RCTs), there has been no recent systematic assessment, and individual trials have studied numerous alternative or control interventions, meaning the best comparator is unclear. We performed a network meta-analysis addressing these uncertainties. DESIGN We searched the medical literature through to 2 April 2021 to identify RCTs of a low FODMAP diet in IBS. Efficacy was judged using dichotomous assessment of improvement in global IBS symptoms or improvement in individual IBS symptoms, including abdominal pain, abdominal bloating or distension, and bowel habit. Data were pooled using a random effects model, with efficacy reported as pooled relative risks (RRs) with 95% CIs, and interventions ranked according to their P-score. RESULTS We identified 13 eligible RCTs (944 patients). Based on failure to achieve an improvement in global IBS symptoms, a low FODMAP diet ranked first vs habitual diet (RR of symptoms not improving=0.67; 95% CI 0.48 to 0.91, P-score=0.99), and was superior to all other interventions. Low FODMAP diet ranked first for abdominal pain severity, abdominal bloating or distension severity and bowel habit, although for the latter it was not superior to any other intervention. A low FODMAP diet was superior to British Dietetic Association (BDA)/National Institute for Health and Care Excellence (NICE) dietary advice for abdominal bloating or distension (RR=0.72; 95% CI 0.55 to 0.94). BDA/NICE dietary advice was not superior to any other intervention in any analysis. CONCLUSION In a network analysis, low FODMAP diet ranked first for all endpoints studied. However, most trials were based in secondary or tertiary care and did not study effects of FODMAP reintroduction and personalisation on symptoms.
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Affiliation(s)
- Christopher J Black
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Heidi M Staudacher
- IMPACT (the Institute for Mental and Physical Health and Clinical Translation), Food & Mood Centre, Deakin University, Geelong, Victoria, Australia
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK .,Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Delivery Methods of Cognitive Behavior Therapy for Patients With Irritable Bowel Syndrome. Gastroenterol Nurs 2022; 45:149-158. [PMID: 35561102 DOI: 10.1097/sga.0000000000000671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022] Open
Abstract
Irritable bowel syndrome (IBS) is the most commonly diagnosed gastrointestinal disorder and negatively impacts individuals' quality of life. Cognitive behavioral therapy appears effective for reducing symptoms in many irritable bowel syndrome patients. However, the optimal methods to deliver cognitive behavioral therapy and the effective treatment dosage for patients with IBS remain unclear. This article aims to provide an update on cognitive behavioral therapy research in IBS, particularly considering the dose of treatment, route of delivery (in-person vs. web- and telephone-based delivery), and outcome measures. A systematic literature review was conducted using databases of PubMed, CINAHL Complete, and Web of Science from 2008 through 2021. Twelve studies reporting randomized clinical trials comparing cognitive behavioral therapy delivered with in-person, telephone, and web for the management of IBS symptoms among adults with irritable bowel syndrome were found. The dose of treatment varied from 4 to 10 sessions. Six different scales measured various outcomes. No severe adverse reactions to cognitive behavioral therapy were reported. Cognitive behavioral therapy is an effective treatment for IBS symptoms regardless of the dose and the route of treatment. However, it is difficult to compare the effectiveness of these randomized clinical trials due to the various cognitive behavioral therapy protocols, combined routes of therapy delivery, and different outcome measures used.
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Chey WD, Hashash JG, Manning L, Chang L. AGA Clinical Practice Update on the Role of Diet in Irritable Bowel Syndrome: Expert Review. Gastroenterology 2022; 162:1737-1745.e5. [PMID: 35337654 DOI: 10.1053/j.gastro.2021.12.248] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
DESCRIPTION Irritable bowel syndrome (IBS) is a commonly diagnosed gastrointestinal disorder that can have a substantial impact on quality of life. Most patients with IBS associate their gastrointestinal symptoms with eating food. Mounting evidence supports dietary modifications, such as the low-fermentable oligo-, di-, and monosaccharides and polyols (FODMAP) diet, as a primary treatment for IBS symptoms. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the role of diet in IBS treatment. METHODS This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet in treating patients with IBS. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Dietary advice is ideally prescribed to patients with IBS who have insight into their meal-related gastrointestinal symptoms and are motivated to make the necessary changes. To optimize the quality of teaching and clinical response, referral to a registered dietitian nutritionist (RDN) should be made to patients who are willing to collaborate with a RDN and patients who are not able to implement beneficial dietary changes on their own. If a gastrointestinal RDN is not available, other resources can assist with implementation of diet interventions. BEST PRACTICE ADVICE 2: Patients with IBS who are poor candidates for restrictive diet interventions include those consuming few culprit foods, those at risk for malnutrition, those who are food insecure, and those with an eating disorder or uncontrolled psychiatric disorder. Routine screening for disordered eating or eating disorders by careful dietary history is critical because they are common and often overlooked in gastrointestinal conditions. BEST PRACTICE ADVICE 3: Specific diet interventions should be attempted for a predetermined length of time. If there is no clinical response, the diet intervention should be abandoned for another treatment alternative, for example, a different diet, medication, or other form of therapy. BEST PRACTICE ADVICE 4: In preparation for a visit with a RDN, patients should provide dietary information that will assist in developing an individualized nutrition care plan. BEST PRACTICE ADVICE 5: Soluble fiber is efficacious in treating global symptoms of IBS. BEST PRACTICE ADVICE 6: The low-FODMAP diet is currently the most evidence-based diet intervention for IBS. Healthy eating advice as described by the National Institute of Health and Care Excellence Guidelines, among others, also offers benefit to a subset of patients with IBS. BEST PRACTICE ADVICE 7: The low-FODMAP diet consists of the following 3 phases: 1) restriction (lasting no more than 4-6 weeks), 2) reintroduction of FODMAP foods, and 3) personalization based on results from reintroduction. BEST PRACTICE ADVICE 8: Although observational studies found that most patients with IBS improve with a gluten-free diet, randomized controlled trials have yielded mixed results. BEST PRACTICE ADVICE 9: There are limited data showing that selected biomarkers can predict response to diet interventions in patients with IBS, but there is insufficient evidence to support their routine use in clinical practice.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida; Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon
| | - Laura Manning
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
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Abstract
INTRODUCTION Patients with irritable bowel syndrome (IBS) frequently resort to natural products, or request doctors to prescribe them, to relieve their symptoms, due to the poor efficacy and tolerability of several traditional drugs. Products containing fiber are among the most used and their clinical efficacy is discussed here based on the most recent scientific evidence. AREAS COVERED A literature search was carried out to identify the most significant publications in order to deal with the topics of the general characteristics of fibers and the scientific evidence underlying their therapeutic use, the properties of ispaghula husk and the mechanisms by which this product carries out its therapeutic actions. EXPERT OPINION The most recent clinical guidelines on the management of IBS consider ispaghula husk, a product containing soluble fiber, as a reasonable first line therapy for IBS patients with symptoms. In contrast, products containing insoluble fibers, particularly wheat bran, do not appear to be useful in treating IBS symptoms. The clinical data on the use of prebiotics in IBS are still inconclusive. However, low daily amounts of fructo-oligosaccharides or β-galacto-oligosaccharides (also known as trans-galacto-oligosaccharides) may be effective in improving IBS symptoms; further trials are needed to definitively establish their clinical usefulness.
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Affiliation(s)
- Diego Currò
- Dipartimento Di Sicurezza E Bioetica, Sezione Di Farmacologia, Università Cattolica Del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
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64
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Harris LA, Cash BD, Moftah K, Franklin H. An Open-label, Multicenter Study to Assess the Efficacy and Safety of a Novel Probiotic Blend in Patients With Functional Gastrointestinal Symptoms. J Clin Gastroenterol 2022; 56:444-451. [PMID: 34028393 PMCID: PMC8989638 DOI: 10.1097/mcg.0000000000001567] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/09/2021] [Indexed: 12/19/2022]
Abstract
GOAL A novel 5-strain (Bl-04, Bi-07, HN019, NCFM, and Lpc-37) probiotic blend was developed and its safety and efficacy were evaluated in patients with functional gastrointestinal (GI) symptoms. BACKGROUND These strains administered together have not previously been investigated. STUDY Patients aged 18 to 75 years with functional GI symptoms were eligible for inclusion in a single-arm, open-label, multicenter study (NCT04155801). An oral capsule containing the novel probiotic blend was administered once daily for 30 days. The primary efficacy endpoint was patient-reported improvement in overall GI well-being at day 30. Secondary efficacy endpoints included changes in GI symptoms assessed using the GI Health Symptom Questionnaire. Incidence of treatment-emergent adverse events was recorded at all visits. RESULTS Of 188 enrolled patients, 72.3% were female and mean (SD) age was 44.1 (13.4) years. At day 30, 85.1% of patients achieved the primary endpoint, a positive response signifying improvement in overall GI well-being. Improvements from baseline were reported at day 30 in diarrhea frequency (baseline frequency≥3 to 4 d/wk) and severity (baseline severity≥5/10) for 75.8% and 87.3% of patients, respectively. Over the same time period, constipation frequency (baseline frequency≥3 to 4 d/wk) and severity (baseline severity≥5/10) improved in 73.6% and 80.4% of patients, respectively. Most patients reported improvements at day 30 in frequency and severity of straining, urgency, abdominal pain/discomfort, bloating, and distention. Improvements reported at day 30 were generally observable at day 14. No safety signals were identified. CONCLUSION A novel 5-strain probiotic blend improved functional GI symptoms and was safe.
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Affiliation(s)
- Lucinda A. Harris
- Division of Gastroenterology and Hepatology, Mayo Clinic, Alix School of Medicine, Scottsdale, AZ
| | - Brooks D. Cash
- Division of Gastroenterology, Hepatology, and Nutrition, University of Texas Health Science Center, Houston, TX
| | | | - Howard Franklin
- Salix Pharmaceuticals, A Division of Bausch Health US LLC, Bridgewater, NJ
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Assessing the post-treatment therapeutic effect of tongxie in irritable bowel syndrome: a randomized controlled trial. Complement Ther Med 2022; 68:102839. [PMID: 35483627 DOI: 10.1016/j.ctim.2022.102839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 11/09/2022] Open
Abstract
Diarrhea predominant irritable bowel syndrome (IBS) is a highly relapsing gastrointestinal disorder decreasing the quality of life. Existing studies indicated that the therapeutic effects maintained for a period of time after the treatments were discontinued (post-treatment therapeutic effects or PTTE). In this study, we aim to assess the PTTE of tongxie. We performed a multiple center, controlled, double blind study of patients with IBS randomized to tongxie (n=120) or placebo (n=120) for 4 weeks and followed up for 57 weeks. The primary outcomes were abdominal pains and stool consistency. The secondary outcomes were pain frequency and stool frequency. Tertiary outcomes were adverse effects and global overall symptom. The outcome data were collected at days 1, 2, 3, weeks 1 and 4 during the treatment and at days 1, 2, 3, until week 57 during the post-treatment. Significantly more patients receiving tongxie were clinical responders to the primary and secondary endpoints from day 1 until the end of the treatment. The positive effects of tongxie were maintained until 17 to 25 weeks after tongxie was discontinued. The relapse-free probabilities in the tongxie group were significantly higher than those in the placebo group (P <.001). Twenty-five weeks after the therapies were discontinued could be considered as IBS natural history. During this period, an average of 53.8% - 56.3% of patients (pool tongxie and placebo data together) had IBS symptoms (pain scale ≥ 3, stool consistency ≥ 5). In particular, at the end of this study (week 61), 145 (54.2%) patients had IBS symptoms. Our results provide clinical insights into efficient and cost-effective management of refractory IBS, and lend support to the IBS management that the selection of a therapy should consider both its effectiveness during treatment and its PTTE after the treatment. Clinicaltrials.gov no: NCT02330029.
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66
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Mechanisms of Action of Current Pharmacologic Options for the Treatment of Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation. Am J Gastroenterol 2022; 117:S6-S13. [PMID: 35354770 DOI: 10.14309/ajg.0000000000001687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/31/2022] [Indexed: 12/11/2022]
Abstract
Multiple therapeutic agents are currently available for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation. A better understanding of the mechanism of action of each treatment provides important insights into expected responses and is key to optimizing treatment outcomes. Some constipation treatments, such as stimulant laxatives, may increase bowel movement frequency but are ineffective at relieving, and may even exacerbate, abdominal symptoms. On the contrary, prescription treatments, such as the guanylyl cyclase-C agonists, for example, may improve bowel symptoms and reduce visceral hypersensitivity. This review summarizes the mechanisms of action of commonly used over-the-counter and prescription therapies for chronic idiopathic constipation and irritable bowel syndrome with constipation, outlining how these mechanisms contribute to the efficacy and safety of each treatment option.
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Kindt S, Louis H, De Schepper H, Arts J, Caenepeel P, De Looze D, Gerkens A, Holvoet T, Latour P, Mahler T, Mokaddem F, Nullens S, Piessevaux H, Poortmans P, Rasschaert G, Surmont M, Vafa H, Van Malderen K, Vanuytsel T, Wuestenberghs F, Tack J. Belgian consensus on irritable bowel syndrome. Acta Gastroenterol Belg 2022; 85:360-382. [PMID: 35709780 DOI: 10.51821/85.2.10100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is characterised by recurrent abdominal pain related to defaecation or associated with altered stool frequency or consistency. Despite its prevalence, major uncertainties in the diagnostic and therapeutic management persist in clinical practice. METHODS A Delphi consensus was conducted by 20 experts from Belgium, and consisted of literature review and voting process on 78 statements. Grading of recommendations, assessment, development and evaluation criteria were applied to evaluate the quality of evidence. Consensus was defined as > 80 % agreement. RESULTS Consensus was reached for 50 statements. The Belgian consensus agreed as to the multifactorial aetiology of IBS. According to the consensus abdominal discomfort also represents a cardinal symptom, while bloating and abdominal distension often coexist. IBS needs subtyping based on stool pattern. The importance of a positive diagnosis, relying on history and clinical examination is underlined, while additional testing should remain limited, except when alarm features are present. Explanation of IBS represents a crucial part of patient management. Lifestyle modification, spasmolytics and water-solube fibres are considered first-line agents. The low FODMAP diet, selected probiotics, cognitive behavioural therapy and specific treatments targeting diarrhoea and constipation are considered appropriate. There is a consensus to restrict faecal microbiota transplantation and gluten-free diet, while other treatments are strongly discouraged. CONCLUSIONS A panel of Belgian gastroenterologists summarised the current evidence on the aetiology, symptoms, diagnosis and treatment of IBS with attention for the specificities of the Belgian healthcare system.
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Affiliation(s)
- S Kindt
- Department of gastroenterology and Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - H Louis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - H De Schepper
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - J Arts
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology, AZ Sint-Lucas, Brugge, Belgium
| | - P Caenepeel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology, Ziekenhuis Oost-Limburg, Campus Sint-Jan, Genk, Belgium
- UHasselt, Hasselt, Belgium
| | - D De Looze
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
| | - A Gerkens
- Boitsfort Medical Center, Brussels, Belgium
| | - T Holvoet
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
- Department of Gastroenterology, AZ Nikolaas, Sint Niklaas, Belgium
| | - P Latour
- Department of Gastroenterology, Hepatology and Digestive Oncology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - T Mahler
- Department of Pediatrics, Universitair Ziekenuis Brussel, Brussel, Belgium
| | - F Mokaddem
- Department of Gastroenterology and Hepatology, Vivalia-Centre Sud Luxembourg, Arlon, Belgium
| | - S Nullens
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - H Piessevaux
- Department of Hepato-gastroenterology, Cliniques universitaires St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - P Poortmans
- Department of gastroenterology and Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - G Rasschaert
- Department of gastroenterology and Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - M Surmont
- Department of gastroenterology and Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - H Vafa
- Department of Gastroenterology and Hepatology, Chirec-Site Delta, Brussels, Belgium
| | - K Van Malderen
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - T Vanuytsel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - F Wuestenberghs
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - J Tack
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Real-World Treatment Strategies to Improve Outcomes in Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation. Am J Gastroenterol 2022; 117:S21-S26. [PMID: 35354772 DOI: 10.14309/ajg.0000000000001709] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/18/2022] [Indexed: 12/11/2022]
Abstract
Chronic idiopathic constipation and irritable bowel syndrome with constipation are complex, overlapping conditions. Although multiple guidelines have informed healthcare providers on appropriate treatment options for patients with chronic idiopathic constipation and irritable bowel syndrome with constipation, little direction is offered on treatment selection. First-line treatment options usually include fiber and over-the-counter osmotic laxatives; however, these are insufficient for many individuals. When these options fail, prescription secretagogues (plecanatide, linaclotide, lubiprostone, and tenapanor [pending commercial availability]), or serotonergic agents (prucalopride and tegaserod) are generally preferred. Individuals experiencing concurrent abdominal pain and/or bloating may experience greater overall improvements from prescription therapies because these agents have been proven to reduce concurrent abdominal and bowel symptoms. Should initial prescription treatments fail, retrying past treatment options (if not adequately trialed initially), combining agents from alternative classes, or use of adjunctive therapies may be considered. Given the broad spectrum of available agents, therapy should be tailored by mutual decision-making between the patient and practitioner. Overall, patients need to be actively monitored and managed to maximize clinical outcomes.
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69
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Qin D, Tao QF, Huang SL, Chen M, Zheng H. Eluxadoline Versus Antispasmodics in the Treatment of Irritable Bowel Syndrome: An Adjusted Indirect Treatment Comparison Meta-analysis. Front Pharmacol 2022; 13:757969. [PMID: 35281934 PMCID: PMC8906885 DOI: 10.3389/fphar.2022.757969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Objective: Eluxadoline is a newly approved drug for irritable bowel syndrome (IBS), but it has rarely been compared with positive controls. We aimed to compare eluxadoline with antispasmodics in the treatment of IBS. Methods: We searched the OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials databases for randomized controlled trials (RCTs) comparing eluxadoline or antispasmodics with placebo. The search was conducted from 1 January 1980, to 1 September 2020, without any language restrictions. The primary efficacy outcome was the relief of abdominal pain, defined by a reduction of pain scores of at least 30% from baseline. The secondary efficacy outcome was the relief of global IBS symptoms, defined by a composite response of a decrease in abdominal pain and improvement in stool consistency on the same day for at least 50% of the days assessed. The data were pooled using a random-effects model. Outcome estimates were pooled by using Risk Ratios (RRs) and P-scores. Results: Forty-two trials with 8,457 participants were included from 45 articles. Compared with placebo, each of drotaverine, pinaverium, alverine combined with simethicone (ACS) and eluxadoline 100 mg was highly effective in the relief of abdominal pain, with drotaverine [RR, 2.71 (95% CI, 1.70 to 4.32), P-score = 0.95] ranking first. Drotaverine, otilonium, cimetropium, pinaverium, and eluxadoline 100 mg had significantly high the relief of global IBS symptomss, for which drotaverine [RR, 2.45 (95% CI, 1.42 to 4.22), P-score = 0.95] was ranked first. No significant difference was found between these interventions. Pinaverium had a significantly higher the relief of global IBS symptoms than eluxadoline [RR, 1.72 (95% CI, 1.33 to 2.21)] on sensitivity analysis. However, no significant difference was found in the number of adverse events between each intervention and the placebo. Conclusion: Our network meta-analysis showed that eluxadoline 100 mg was at least as effective as antispasmodics in relieving abdominal pain in IBS. But eluxadoline had more reported adverse events. Antispasmodics are still the first choice for the treatment of IBS.
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Affiliation(s)
- Di Qin
- Third Hospital/Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qing-Feng Tao
- Third Hospital/Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shi-Le Huang
- Acupuncture department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Min Chen
- Department of Colorectal Diseases, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hui Zheng
- Third Hospital/Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Abstract
Opioid-related constipation encompasses constipation directly caused by opioid use (opioid-induced constipation [OIC]) as well as pre-existing constipation worsened by opioid use (opioid-exacerbated constipation [OEC]). Over-the-counter laxatives should be used as first-line agents for both OIC and OEC, given their efficacy, low cost, and high safety profiles. Symptoms of OIC and responses to therapy can be assessed with the Bowel Function Index. Individuals with OIC refractory to laxatives may be responsive to peripherally acting μ-opioid receptor antagonists. Although data supporting the superiority of one prescription agent over another is lacking, all have proven effective for the treatment of OIC.
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71
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Evaluating tolerability of resistant starch 2, alone and in combination with minimally fermented fibre for patients with irritable bowel syndrome: a pilot randomised controlled cross-over trial. J Nutr Sci 2022; 11:e15. [PMID: 35291272 PMCID: PMC8889220 DOI: 10.1017/jns.2022.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 02/07/2023] Open
Abstract
Resistant starch 2 (RS2) may offer therapeutic value to irritable bowel syndrome (IBS) patients particularly in combination with minimally fermented fibre, but tolerability data are lacking. The present study evaluated the tolerability of RS2, sugarcane bagasse and their combination in IBS patients and healthy controls. Following baseline, participants consumed the fibres in escalating doses lasting 3 d each: RS2 (10, 15 and 20 g/d); sugarcane bagasse (5, 10 and 15 g/d); and their combination (20, 25 and 30 g/d). Gastrointestinal symptoms were assessed daily. Six IBS patients and five controls were recruited. No differences in overall symptoms from baseline were found across the fibre doses (IBS, P = 0⋅586; controls, P = 0⋅687). For IBS patients, all RS2 doses led to increased bloating. One IBS patient did not tolerate the low combination dose and another the high sugarcane bagasse dose. Supplementation of RS2 ≤ 20 g/d caused mild symptoms and was generally tolerated in IBS patients even when combined with minimally fermented fibre.
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72
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Rastgoo S, Ebrahimi-Daryani N, Agah S, Karimi S, Taher M, Rashidkhani B, Hejazi E, Mohseni F, Ahmadzadeh M, Sadeghi A, Hekmatdoost A. Glutamine Supplementation Enhances the Effects of a Low FODMAP Diet in Irritable Bowel Syndrome Management. Front Nutr 2022; 8:746703. [PMID: 34977110 PMCID: PMC8716871 DOI: 10.3389/fnut.2021.746703] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aims: Although irritable bowel syndrome is one of the most common gastrointestinal disorders presented to gastroenterologists, therapeutic strategies are not yet well-established. Accordingly, we conducted a randomized, double-blind, placebo-controlled, clinical trial to evaluate the possible superiority of adding glutamine supplement to low fermentable oligo- di- monosaccharides and polyols (FODMAP) diet in patients with irritable bowel syndrome (IBS). Methods: Eligible adults were randomized to receive a low FODMAP diet either with glutamine (15 g/day) or a placebo for 6 weeks. The primary endpoint was a significant reduction in IBS-symptom severity score (IBS-SSS). Secondary endpoints were changes in IBS symptoms, stool frequency, consistency, and quality of life. Results: The study group enrolled 50 patients, among which 22 participants from each group completed the study protocol. The glutamine group had significant changes in total IBS-severity score, dissatisfaction of bowel habit and interference with community function (58% reduction; P < 0.001, 57% reduction; P < 0.001, 51% reduction; P = 0.043, respectively). Improvement in IBS-severity score of more than 45% was observed in 22 of 25 participants (88%) in the glutamine group, while it was only 15 of 25 participants (60%) in the control group (p = 0.015). No serious adverse events were observed. Conclusions: Our findings indicated the superiority of adding glutamine supplementation to a low FODMAP diet in amelioration of IBS symptoms while confirming the beneficial effects of a low FODMAP diet in IBS management.
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Affiliation(s)
- Samira Rastgoo
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasser Ebrahimi-Daryani
- Department of Gastroenterology and Hepatology, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahram Agah
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sara Karimi
- Department of Gastroenterology and Hepatology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taher
- Department of Gastroenterology and Hepatology, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Rashidkhani
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ehsan Hejazi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Mohseni
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mina Ahmadzadeh
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azita Hekmatdoost
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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73
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World Gastroenterology Organisation Global Guidelines: Diet and the Gut. J Clin Gastroenterol 2022; 56:1-15. [PMID: 34860201 DOI: 10.1097/mcg.0000000000001588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 05/22/2021] [Indexed: 12/10/2022]
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Meling S, Bertoli D, Sangnes DA, Brock C, Drewes A, Ejskjaer N, Dimcevski G, Søfteland E. Diabetic Gastroenteropathy: Soothe the Symptoms or Unravel a Cure? Curr Diabetes Rev 2022; 18:e220321192412. [PMID: 34225633 DOI: 10.2174/1573399817666210322154618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/13/2021] [Indexed: 11/22/2022]
Abstract
Autonomic neuropathy in patients with diabetes mellitus, and especially complications related to gastrointestinal neuropathy, are often overlooked in the clinic. Diabetic gastroenteropathy affects every segment of the gastrointestinal tract and generates symptoms that may include nausea, early satiety, vomiting, abdominal pain, constipation, and diarrhea. Severe cases can be complicated by weight loss, dehydration, and electrolyte disturbances. The pathophysiology is complex, the diagnostics and treatment options are multidisciplinary, and there is generally a lack of evidence for the treatment options. The aims for this review are first to summarize the pathophysiology and describe possible and expected symptoms and complications.Further, we will try to supply the clinician with a straightforward tool for diagnostics, and then, we shall summarize established treatment options, including diet recommendations, pharmacological and non-pharmacological options. Finally, we will explore the multiple possibilities of novel treatment, looking at medications related to the pathophysiology of neuropathy, other manifestations of autonomic neuropathies, and symptomatic treatment for other gastrointestinal disorders, also including new knowledge of endosurgical and neuromodulatory treatment. The overall goal is to increase awareness and knowledge on this frequent diabetic complication and to provide better tools for diagnosis and treatment. Ultimately, we hope to encourage further research in this field, as there are clear shortcomings in terms of biomarkers, pathophysiology, as well as treatment possibilities. In conclusion, diagnosis and management of diabetic gastroenteropathy are challenging and often require multidisciplinary teams and multimodal therapies. Treatment options are sparse, but new pharmacological, endoscopic, and neuromodulatory techniques have shown promising results in initial studies.
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Affiliation(s)
- Sondre Meling
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Davide Bertoli
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Dag A Sangnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Asbjørn Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Lambarth A, Zarate-Lopez N, Fayaz A. Oral and parenteral anti-neuropathic agents for the management of pain and discomfort in irritable bowel syndrome: A systematic review and meta-analysis. Neurogastroenterol Motil 2022; 34:e14289. [PMID: 34755926 DOI: 10.1111/nmo.14289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a highly prevalent and economically burdensome condition; and pain is often the most unpleasant, disruptive, and difficult-to-treat symptom. Visceral hypersensitivity is a common feature driving pain in IBS, suggesting that neuropathic mechanisms may be implicated. We conducted a systematic review of available evidence to examine the role of anti-neuropathic medicines in the management of pain in IBS. METHODS We systematically searched scientific repositories for trials investigating conventional oral, and/or parenteral, pharmaceutical antineuropathic treatments in patients with IBS. We summarized key participant characteristics, outcomes related to pain (primary outcome), and selected secondary outcomes. KEY RESULTS We included 13 studies (n = 629 participants): six investigated amitriptyline, three duloxetine, three pregabalin, and one gabapentin. There was considerable methodological and statistical heterogeneity, so we performed a narrative synthesis and limited meta-analysis. Amitriptyline was most extensively studied, though only in diarrhea-predominant patients. In individual trials, amitriptyline, pregabalin and gabapentin generally appeared beneficial for pain outcomes. While duloxetine studies tended to report improvements in pain, all were un-controlled trials with high risk of bias. Meta-analysis of three studies (n = 278) yielded a pooled relative-risk of 0.50 (95%CI 0.38-0.66) for not improving with anti-neuropathic agent vs control. We did not identify any eligible studies investigating the role of parenteral anti-neuropathics. CONCLUSIONS AND INFERENCES Anti-neuropathic analgesics may improve pain in IBS, and deserve further, high-quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Investigation of amitriptyline's efficacy in non-diarrhea-predominant subtypes is currently lacking, and we recommend particular caution for its use in IBS-C.
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Affiliation(s)
- Andrew Lambarth
- University College London Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Natalia Zarate-Lopez
- University College London Hospital Gastrointestinal Physiology Unit, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Alan Fayaz
- University College Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
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BouSaba J, Sannaa W, Camilleri M. Pain in irritable bowel syndrome: Does anything really help? Neurogastroenterol Motil 2022; 34:e14305. [PMID: 34859929 PMCID: PMC9017689 DOI: 10.1111/nmo.14305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 01/03/2023]
Abstract
Pain relief remains a significant challenge in the management of irritable bowel syndrome (IBS): "Does anything really help relieve the pain in patients with IBS?". Interventions aimed at pain relief in patients with IBS include diet, probiotics or antibiotics, antidepressants, antispasmodics, and drugs targeting specific gastrointestinal receptors such as opioid or histamine receptors. In the systematic review and meta-analysis published in this journal, Lambarth et al. examined the literature on the role of oral and parenteral anti-neuropathic agents in the management of pain in patients with IBS. This review article appraises their assessment of the efficacy of the anti-neuropathic agents amitriptyline, pregabalin, gabapentin, and duloxetine in the relief of abdominal pain or discomfort, and impact on overall IBS severity and quality of life. This commentary provides an update of current evidence on the efficacy of the dietary and pharmacological treatments that are available or in development, as well psychological and cognitive behavioral therapy for pain in IBS. Advances in recent years augur well for efficacious treatments that may expand the therapeutic arsenal for pain in IBS.
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Affiliation(s)
- Joelle BouSaba
- Division of Gastroenterology and Hepatology Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Mayo Clinic Rochester Minnesota USA
| | - Wassel Sannaa
- Division of Gastroenterology and Hepatology Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Mayo Clinic Rochester Minnesota USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Mayo Clinic Rochester Minnesota USA
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Shah ED, Salwen-Deremer JK, Gibson PR, Muir JG, Eswaran S, Chey WD. Comparing Costs and Outcomes of Treatments for Irritable Bowel Syndrome With Diarrhea: Cost-Benefit Analysis. Clin Gastroenterol Hepatol 2022; 20:136-144.e31. [PMID: 33010413 DOI: 10.1016/j.cgh.2020.09.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is one of the most expensive gastroenterological conditions and is an ideal target for developing a value-based care model. We assessed the comparative cost-benefit of treatments for IBS with diarrhea (IBS-D), the most common IBS subtype from insurer and patient perspectives. METHODS We constructed a decision analytic model assessing trade-offs among guideline-recommended and recently FDA-approved drugs, supplements, low FODMAP diet, cognitive behavioral therapy (CBT). Outcomes and costs were derived from systematic reviews of clinical trials and national databases. Health-gains were represented using quality-adjusted life years (QALY). RESULTS From an insurer perspective, on-label prescription drugs (rifaximin, eluxadoline, alosetron) were significantly more expensive than off-label treatments, low FODMAP, or CBT. Insurer treatment preferences were driven by average wholesale prescription drug prices and were not affected by health gains in sensitivity analysis within standard willingness-to-pay ranges up to $150,000/QALY-gained. From a patient perspective, prescription drug therapies and neuromodulators appeared preferable due to a reduction in lost wages due to IBS with effective therapy, and also considering out-of-pocket costs of low FODMAP food and out-of-pocket costs to attend CBT appointments. Comparative health outcomes exerted influence on treatment preferences from a patient perspective in cost-benefit analysis depending on a patients' willingness-to-pay threshold for additional health-gains, but health outcomes were less important than out-of-pocket costs at lower willingness-to-pay thresholds. CONCLUSIONS Costs are critical determinants of IBS treatment value to patients and insurers, but different costs drive patient and insurer treatment preferences. Divergent cost drivers appear to explain misalignment between patient and insurer IBS treatment preferences in practice.
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Jessica K Salwen-Deremer
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia
| | - Jane G Muir
- Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia
| | - Shanti Eswaran
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
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78
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Marlicz W, Skonieczna-Żydecka K, Krynicka P, Łoniewski I, Rydzewska G. Probiotics in irritable bowel syndrome - is the quest for the right strain over? Rapid review of existing guidelines and recommendations. PRZEGLAD GASTROENTEROLOGICZNY 2021; 16:369-382. [PMID: 34976247 PMCID: PMC8690954 DOI: 10.5114/pg.2021.111766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/30/2021] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) - functional gastrointestinal disorder (FGIDs) and disorder of gut-brain interaction (DGBIs) - has emerged as an important medical problem with an impact on health care systems, affecting patients' quality of life. The management of IBS consists of pharmacological and non-pharmacological treatments; however, the data of their long-term efficacy are scarce. Modulation of gastrointestinal microbiota, by means of probiotics and prebiotics, is often sought and advertised as a popular treatment modality in IBS. Faecal microbiota transplantation (FMT) awaits recommendations for IBS treatment and requires more methodological assessments. To date, numerous guidelines and recommendations have been published on the role of probiotics in IBS. Because no probiotic claim for probiotics in foods has yet been granted by the European Food and Safety Authority (EFSA), medical practitioners still recommend probiotics on the basis of available literature and recommendations released by independent health authorities. We aimed to summarize published formal recommendations and guidelines regarding the clinical effectiveness of available probiotic strains and conduct a random-effects meta-analysis of outcomes for which ≥ 2 studies contributed data on the same probiotic strain recommended to adults with IBS. Based on available and most recent guidelines, we report that probiotics, as a group, may be an effective treatment for global symptoms and abdominal pain in IBS, with the strongest effect for genus Lactobacillus. Our current and updated meta-analysis is in line with several reports documenting significant effects of Lactobacillus plantarum (Lp299v) in reducing the risk of global symptoms and their persistence, which could assist clinicians in making the choice for the right probiotic strain in IBS patients.
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Affiliation(s)
- Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | | | - Patrycja Krynicka
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Igor Łoniewski
- Department of Biochemical Sciences, Pomeranian Medical University, Szczecin, Poland
| | - Grażyna Rydzewska
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Unit, Central Clinical Hospital of the Ministry of the Inferior and Administration, Warsaw, Poland
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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79
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A Network Pharmacology-Based Study on Irritable Bowel Syndrome Prevention and Treatment Utilizing Shenling Baizhu Powder. BIOMED RESEARCH INTERNATIONAL 2021; 2021:4579850. [PMID: 34859100 PMCID: PMC8632384 DOI: 10.1155/2021/4579850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023]
Abstract
Methods Metabolomics was used to detect the secondary metabolites in SLBZP; the target protein was acquired by target fishing according to the compound's structure. The SymMap database was used to search herbal medicines for the target protein. The target gene of IBS gave rise to the common gene protein which is the potential target of SLBZP in IBS therapy. The interactions between target proteins were analyzed in a STRING database, the protein relationship network was analyzed using Cytoscape software, and the Kyoto Encyclopedia of Genes and Genomes enrichment analysis of the core target gene group was carried out in a DAVID database in order to construct the “compound-traditional Chinese medicine/molecule-target-pathway” network. Molecular docking was used to verify the core protein and its related small molecular compounds. Result There were 129 types of secondary metabolites in SLBZP. 80 target proteins of these metabolites were potential core targets for IBS treatment including acetylcholinesterase (AChE), arachidonate-5-lipoxygenase (ALOX5), B-cell lymphoma-2 (BCL2), recombinant cyclin D1 (CCND1), and catenin-β1 (CTNNB1), among others. Results from these targets indicated that the most enriched pathway was the tumor necrosis factor (TNF) signaling pathway (p < 0.001) and that the most abundant pathway was signal transduction. In the network nodes of the TNF signaling pathway, the Chinese medicines with the highest aggregation were Lablab semen album and Glycyrrhizae radix et rhizoma (degree = 11). The small molecules with the highest aggregation were oxypeucedanin and 3,5,6,7,8,3′,4′-heptamethoxyflavone (degree = 4). Molecular docking results confirmed that daidzein 7-O-glucoside (daidzin) had the highest degree of binding to TNF proteins in the TNF signaling pathway. Conclusion This study shows that SLBZP can treat IBS by influencing multiple targets and pathways, of which the TNF signaling pathway may be the most significant. This typifies the pharmacological characteristics of traditional Chinese medicine, i.e., multiple targets, numerous pathways, and specific therapeutic effects on diseases. SLBZP can therefore be used as a candidate drug for clinical IBS by intervening in human signal transduction.
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Shah ED, Chang L, Lembo A, Staller K, Curley MA, Chey WD. Price Is Right: Exploring Prescription Drug Coverage Barriers for Irritable Bowel Syndrome Using Threshold Pricing Analysis. Dig Dis Sci 2021; 66:4140-4148. [PMID: 33433804 DOI: 10.1007/s10620-020-06806-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prescription drug costs exert profound effects on commercial insurance coverage and access to effective therapy. AIMS We aimed to assess threshold pricing to achieve budget neutrality of FDA-approved drugs treating irritable bowel syndrome from an insurance perspective, based on cost-savings resulting in decreased healthcare utilization through effective disease management. METHODS We constructed a decision-analytic model from an insurance perspective to assess the budget impact of IBS prescription drugs under usual insurance coverage levels in practice: (1) unrestricted drug access or (2) step therapy in a primary care population of middle-age, care-seeking IBS patients. Budget-neutral drug prices were then calculated which resulted in $0 budget impact to insurers with a short-term, one-year time horizon. RESULTS If used according to FDA labeling, IBS-D drugs cost between $4778 and $16,844 per year and IBS-C drugs cost between $4319 and $4955 per year. These drug costs often exceed insurance expenditures of $6999 for IBS-D and $3929 for IBS-C if left untreated. Therefore, for drugs to have $0 budget impact to insurers, their prices would need to be discounted 36.7-74.2% for IBS-D drugs and 59.3-82.5% for IBS-C. IBS drugs are already priced to support step therapy "failing one of several common, inexpensive IBS treatments with a responder rate > 30-40%," reflecting the subpopulation with more severe disease and greater healthcare costs. CONCLUSIONS Broader prescription drug coverage for patients failing common, inexpensive IBS treatments to which at least 30-40% of patients would typically respond appears warranted to enable gastroenterologists to offer personalized approaches targeting specific mechanisms of this heterogeneous disease.
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Affiliation(s)
- Eric D Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Anthony Lembo
- Digestive Disease Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Curley
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
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Parker CH, Naliboff BD, Shih W, Presson AP, Kilpatrick L, Gupta A, Liu C, Keefer LA, Sauk JS, Hirten R, Sands BE, Chang L. The Role of Resilience in Irritable Bowel Syndrome, Other Chronic Gastrointestinal Conditions, and the General Population. Clin Gastroenterol Hepatol 2021; 19:2541-2550.e1. [PMID: 32835842 PMCID: PMC7897330 DOI: 10.1016/j.cgh.2020.08.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Resilience is the ability to adapt positively to stress and adversity. It is a potential therapeutic target as it is reduced in irritable bowel syndrome (IBS) compared to healthy controls and associated with worse symptom severity and poorer quality of life. The aim of this study was to examine if these findings are generalizable by comparing resilience between IBS versus the general population and other chronic gastrointestinal (GI) conditions. METHODS Participants in the general population completed an online survey containing questionnaires measuring demographics, diagnosis of IBS and other GI conditions, symptom severity, psychological symptoms, resilience, and early adverse life events (EALs). IBS was defined as having a physician diagnosis of IBS and/or meeting Rome criteria without co-morbid GI disease. All others were included in the general population group. The chronic GI conditions group included those with inflammatory bowel disease, celiac disease and/or microscopic colitis. RESULTS Resilience was lower in IBS (n = 820) than the general population (n = 1026; p < 0.001) and associated with worse IBS symptom severity (p < 0.05). Global mental health affected resilience differently in IBS compared to the general population (all p's < 0.05). EALs were associated with decreased ability to bounce back from adversity in both IBS and the general population (p < 0.001). Resilience scores were similar in IBS and other chronic GI conditions that present with similar symptoms. CONCLUSIONS Resilience is lower compared to the general U.S. population but does not appear to be specific to IBS as it is comparable to other chronic GI conditions. Low resilience negatively affects symptom severity and mental health and thus, may serve as a novel therapeutic target.
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Affiliation(s)
- Colleen H Parker
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce D Naliboff
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Wendy Shih
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City Utah
| | - Lisa Kilpatrick
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Arpana Gupta
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Cathy Liu
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Laurie A Keefer
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jenny S Sauk
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Robert Hirten
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lin Chang
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California.
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Almario CV, Eberlein S, Khalil C, Spiegel BM. Determining patient treatment preferences for management of acute pain episodes in irritable bowel syndrome. Neurogastroenterol Motil 2021; 33:e14145. [PMID: 33797116 PMCID: PMC8486892 DOI: 10.1111/nmo.14145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/19/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many patients with irritable bowel syndrome (IBS) experience acute and unexpected pain episodes over and above chronic background symptoms, and there are emerging medications designed to treat such pain. We aimed to use conjoint analysis-a technique that elucidates how people make complex decisions-to examine patient preferences for emerging medicines for breakthrough IBS pain. METHODS We conducted a cross-sectional conjoint analysis survey among patients with Rome IV IBS and recurrent episodes of acute pain to assess the relative importance of medication attributes in their decision-making. We also assessed what respondents would require of subcutaneous (SQ) therapies to consider their use. KEY RESULTS Among 629 patients with Rome IV IBS, 606 (96.3%) reported ≥1 acute pain episodes in the past month. For the 461 participants with multiple attacks who completed the conjoint analysis, they prioritized medication efficacy (importance score 34.9%), avoidance of nausea (24.3%), and avoidance of constipation (12.2%) as most important in their decision-making. These were followed by route of administration (10.3%), avoidance of headache (9.3%), and avoidance of drowsiness (8.9%). Moreover, 431 (93.5%) participants would consider SQ therapies for their acute pain; they had varying expectations on the minimum pain decrease and onset and duration of pain relief needed for considering their use. CONCLUSIONS AND INFERENCES The vast majority of patients with IBS experience breakthrough pain, and when selecting among therapies, they prioritize efficacy and most are willing to use a rapid-acting SQ treatment. These results support development of novel, effective medications-oral or SQ-for management of acute pain attacks.
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Affiliation(s)
- Christopher V. Almario
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
- Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Samuel Eberlein
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Carine Khalil
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Brennan M.R. Spiegel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
- Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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83
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So D, Gibson PR, Muir JG, Yao CK. Dietary fibres and IBS: translating functional characteristics to clinical value in the era of personalised medicine. Gut 2021; 70:2383-2394. [PMID: 34417199 DOI: 10.1136/gutjnl-2021-324891] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/04/2021] [Indexed: 12/16/2022]
Abstract
Clinical guidelines in the use of fibre supplementation for patients with IBS provide one-size-fits-all advice, which has limited value. This narrative review addresses data and concepts around the functional characteristics of fibre and subsequent physiological responses induced in patients with IBS with a view to exploring the application of such knowledge to the precision use of fibre supplements. The key findings are that first, individual fibres elicit highly distinct physiological responses that are associated with their functional characteristics rather than solubility. Second, the current evidence has focused on the use of fibres as a monotherapy for IBS symptoms overall without attempting to exploit these functional characteristics to elicit specific, symptom-targeted effects, or to use fibre types as adjunctive therapies. Personalisation of fibre therapies can therefore target several therapeutic goals. Proposed goals include achieving normalisation of bowel habit, modulation of gut microbiota function towards health and correction of microbial effects of other dietary therapies. To put into perspective, bulking fibres that are minimally fermented can offer utility in modulating indices of bowel habit; slowly fermented fibres may enhance the activities of the gut microbiota; and the combination of both fibres may potentially offer both benefits while optimising the activities of the microbiota throughout the different regions of the colon. In conclusion, understanding the GI responses to specific fibres, particularly in relation to the physiology of the individual, will be the future for personalising fibre therapy for enhancing the personalised management of patients with IBS.
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Affiliation(s)
- Daniel So
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Jane G Muir
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Chu K Yao
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
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84
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Keefer L, Ko CW, Ford AC. AGA Clinical Practice Update on Management of Chronic Gastrointestinal Pain in Disorders of Gut-Brain Interaction: Expert Review. Clin Gastroenterol Hepatol 2021; 19:2481-2488.e1. [PMID: 34229040 DOI: 10.1016/j.cgh.2021.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/07/2021] [Accepted: 07/01/2021] [Indexed: 12/15/2022]
Abstract
DESCRIPTION This expert review summarizes approaches to management of pain in disorders of gut-brain interaction. This review focuses specifically on approaches to pain that persist if first-line therapies aimed at addressing visceral causes of pain are unsuccessful. The roles of a therapeutic patient-provider relationship, nonpharmacologic and pharmacologic therapies, and avoidance of opioids are discussed. METHODS This was not a formal systematic review but was based on a review of the literature to provide best practice advice statements. No formal rating of the quality of evidence or strength of recommendation was performed. BEST PRACTICE ADVICE 1: Effective management of persistent pain in disorders of gut-brain interaction requires a collaborative, empathic, culturally sensitive, patient-provider relationship. BEST PRACTICE ADVICE 2: Providers should master patient-friendly language about the pathogenesis of pain, leveraging advances in neuroscience and behavioral science. Providers also must understand the psychological contexts in which pain is perpetuated. BEST PRACTICE ADVICE 3: Opioids should not be prescribed for chronic gastrointestinal pain because of a disorder of gut-brain interaction. If patients are referred on opioids, these medications should be prescribed responsibly, via multidisciplinary collaboration, until they can be discontinued. BEST PRACTICE ADVICE 4: Nonpharmacologic therapies should be considered routinely as part of comprehensive pain management, and ideally brought up early on in care. BEST PRACTICE ADVICE 5: Providers should optimize medical therapies that are known to modulate pain and be able to differentiate when gastrointestinal pain is triggered by visceral factors vs centrally mediated factors. BEST PRACTICE ADVICE 6: Providers should familiarize themselves with a few effective neuromodulators, knowing the dosing, side effects, and targets of each and be able to explain to the patient why these drugs are used for the management of persistent pain.
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Affiliation(s)
- Laurie Keefer
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cynthia W Ko
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington.
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom; Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
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Liu JJ, Brenner DM. Review article: current and future treatment approaches for IBS with constipation. Aliment Pharmacol Ther 2021; 54 Suppl 1:S53-S62. [PMID: 34927760 DOI: 10.1111/apt.16607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/17/2021] [Accepted: 09/03/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Multiple efficacious therapies are currently available for treating irritable bowel syndrome with constipation (IBS-C). IBS-C specific survey tools that assess symptom relief, treatment satisfaction, and quality of life are important for gauging real-world effectiveness. AIMS/METHODS This article reviews clinical trial efficacy data as well as survey data on adequate relief and quality of life from pivotal trials for lubiprostone, linaclotide, plecanatide, tenapanor, and tegaserod. A brief discussion of agents in development with novel mechanisms of action is also provided. RESULTS/CONCLUSIONS Quality of life and symptom metrics should be standardized and continue to be represented in future IBS-C trials. The choice of agent should be tailored to probability of improving symptoms, safety, tolerability, and cost.
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Affiliation(s)
- Joy J Liu
- Division of Gastroenterology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
| | - Darren M Brenner
- Division of Gastroenterology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
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Luo Y, Keefer L. Role of psychological questionnaires in clinical practice and research within functional gastrointestinal disorders. Neurogastroenterol Motil 2021; 33:e14297. [PMID: 34786802 DOI: 10.1111/nmo.14297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 01/25/2023]
Abstract
Functional gastrointestinal (GI) disorders, also known as disorders of gut-brain interaction (DGBI), affect 40% of the global population. Up to two-thirds of patients with FGIDs experience a major psychological disorder making a thorough psychosocial assessment a critical part of patient care as it can impact treatment approach. Many psychological questionnaires exist in the clinical realm serving different purposes including screening for anxiety and depression, somatization symptoms, health-related anxiety, illness impact, and health-related quality of life. Given the abundance of questionnaires used to screen for similar psychiatric comorbidities, correlation between different instruments is needed to allow for pooling of data. In this issue of Neurogastroenterology & Motility, Snijkers et al. conducted the first comparative study to assess the correlation between the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) to determine optimal cutoffs for diagnosis of depressive and anxiety disorders in a cohort of irritable bowel syndrome patients. The biopsychosocial framework as it applies to FGID has led to the inclusion of both psychosocial assessments in clinical management and research protocols. Future directions include the development of symptom-specific questionnaires for groups of FGIDs, culturally specific psychosocial questionnaires, and inclusion of psychosocial well-being as primary or secondary outcomes in clinical research trials. In this review, we aim to explore the role of psychological questionnaires in clinical care and research trials and share practical tips on incorporating a biopsychosocial framework in the care of patients with FGIDs.
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Affiliation(s)
- Yuying Luo
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laurie Keefer
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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87
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Wollny T, Daniluk T, Piktel E, Wnorowska U, Bukłaha A, Głuszek K, Durnaś B, Bucki R. Targeting the Gut Microbiota to Relieve the Symptoms of Irritable Bowel Syndrome. Pathogens 2021; 10:1545. [PMID: 34959500 PMCID: PMC8705654 DOI: 10.3390/pathogens10121545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a common, chronic, functional disorder with a large impact on world population. Its pathophysiology is not completely revealed; however, it is certain that dysregulation of the bidirectional communications between the central nervous system (CNS) and the gut leads to motility disturbances, visceral hypersensitivity, and altered CNS processing characterized by differences in brain structure, connectivity and functional responsiveness. Emerging evidence suggests that gut microbiota exerts a marked influence on the host during health and disease. Gut microbiome disturbances can be also important for development of IBS symptoms and its modulation efficiently contributes to the therapy. In this work, we review the current knowledge about the IBS therapy, the role of gut microbiota in pathogenesis of IBS, and we discuss that its targeting may have significant impact on the effectiveness of IBS therapy.
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Affiliation(s)
- Tomasz Wollny
- Holy Cross Oncology Center of Kielce, Artwińskiego 3, 25-734 Kielce, Poland;
| | - Tamara Daniluk
- Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2c, 15-222 Białystok, Poland; (T.D.); (E.P.); (U.W.)
| | - Ewelina Piktel
- Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2c, 15-222 Białystok, Poland; (T.D.); (E.P.); (U.W.)
| | - Urszula Wnorowska
- Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2c, 15-222 Białystok, Poland; (T.D.); (E.P.); (U.W.)
| | - Anna Bukłaha
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Białystok, Waszyngtona 15a, 15-269 Białystok, Poland;
| | - Katarzyna Głuszek
- Institute of Medical Science, Collegium Medicum, Jan Kochanowski University in Kielce, 25-734 Kielce, Poland; (K.G.); (B.D.)
| | - Bonita Durnaś
- Institute of Medical Science, Collegium Medicum, Jan Kochanowski University in Kielce, 25-734 Kielce, Poland; (K.G.); (B.D.)
| | - Robert Bucki
- Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2c, 15-222 Białystok, Poland; (T.D.); (E.P.); (U.W.)
- Institute of Medical Science, Collegium Medicum, Jan Kochanowski University in Kielce, 25-734 Kielce, Poland; (K.G.); (B.D.)
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88
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Patient preferences of healthcare delivery in irritable bowel syndrome: a focus group study. BMC Gastroenterol 2021; 21:438. [PMID: 34814846 PMCID: PMC8609738 DOI: 10.1186/s12876-021-02030-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/16/2021] [Indexed: 12/31/2022] Open
Abstract
Background Irritable bowel syndrome (IBS) is a highly prevalent disorder with significant negative impact on quality of life of patients that results in high healthcare use and costs. Improving healthcare outcomes for IBS patients is warranted,
however the exact needs of IBS patients with regard to therapy and control of symptoms are unknown. Methods Focus group interviews, using a two-stage model, were performed with twenty-three IBS patients meeting Rome III criteria and one mother of a patient, from four different regions from the Netherlands. Results Twenty-four participants were included of whom majority were female (n = 21), mean age was 43 years, and mean duration of IBS was 18 years. Five categories of patients’ perspectives were identified: clear communication, a multidisciplinary treatment team, centers of expertise, focus on scientific research and information about IBS that is widely available for patients. Conclusions Based on these findings we highlight the need for IBS care givers to take these key items into account in IBS care. These elements aid clinicians, but mostly patients, in coping and management of symptoms and subsequent healthcare outcomes, reducing overall healthcare use and costs.
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89
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Diarrhea-Predominant and Constipation-Predominant Irritable Bowel Syndrome: Current Prescription Drug Treatment Options. Drugs 2021; 81:1953-1968. [PMID: 34727333 DOI: 10.1007/s40265-021-01634-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 12/14/2022]
Abstract
Irritable bowel syndrome (IBS) is a heterogenous disease with a variety of therapeutic options, including eight prescription drugs approved for use in IBS in the USA. Choosing among the myriad treatment options requires attention to patient preferences both on clinical outcomes and costs associated with treatment. We performed a narrative review of the literature to summarize these important determinants of treatment choice including: labeled indications; clinical profiles of efficacy, safety, and tolerability of prescription drugs; and cost-effectiveness for diarrhea-predominant IBS drugs (IBS-D: alosetron, eluxadoline, and rifaximin) and constipation-predominant IBS drugs (IBS-C: linaclotide, lubiprostone, plecanatide, tegaserod, and tenapanor). We then review the standard model of shared decision-making aimed at guiding an informed, patient-centered discussion to integrate comparative clinical and cost outcomes toward choosing an IBS treatment in practice.
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90
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Quach DT, Vu KT, Vu KV. Prevalence, clinical characteristics, and management of irritable bowel syndrome in Vietnam: A scoping review. JGH Open 2021; 5:1227-1235. [PMID: 34816008 PMCID: PMC8593809 DOI: 10.1002/jgh3.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/19/2021] [Accepted: 07/07/2021] [Indexed: 12/17/2022]
Abstract
Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders worldwide. Its prevalence varies significantly from country to country, largely due to heterogeneity in the available data. Recent studies show that the prevalence of IBS in Asia is on the rise. However, there are very limited data regarding its prevalence in the Vietnamese population. This review aims to offer an overview of the prevalence and clinical characteristics of IBS in the Vietnamese population; and to discuss the current management of IBS in Vietnam-taking into account the available medical resources and the local spectrum of lower gastrointestinal disorders that may mimic IBS.
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Affiliation(s)
- Duc Trong Quach
- Department of Internal MedicineUniversity of Medicine and Pharmacy at Hochiminh CityHo Chi Minh CityVietnam
- Department of GastroenterologyNhan Dan Gia Dinh HospitalHo Chi Minh CityVietnam
| | | | - Khien Van Vu
- Department of Endoscopy108 Central HospitalHanoiVietnam
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91
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Owusu JT, Sibelli A, Moss-Morris R, van Tilburg MAL, Levy RL, Oser M. A pilot feasibility study of an unguided, internet-delivered cognitive behavioral therapy program for irritable bowel syndrome. Neurogastroenterol Motil 2021; 33:e14108. [PMID: 33745228 DOI: 10.1111/nmo.14108] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/23/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is linked with lower health-related quality of life. Cognitive behavioral therapy (CBT) designed for IBS management can improve outcomes but further research of more accessible implementations of this treatment approach for IBS is needed. This study assessed the feasibility of a web-delivered CBT program among adults with IBS to apply to a future clinical trial. METHODS Twenty-five participants were randomized to receive an unguided web-based, CBT program for IBS. The primary outcome was changes in IBS symptom severity (IBS Symptom Severity Scale [IBS-SSS]). Secondary outcomes included IBS-specific CBT therapeutic mechanisms of change (GI-specific anxiety, unhelpful IBS behaviors, and GI-focused cognitions) and changes in depressive (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder-7 scale [GAD-7]) symptom severity. KEY RESULTS Among participants randomized to receive web-based CBT, the average baseline IBS-SSS score was 296.3 (SD=100.9). IBS symptom severity significantly improved at 2-month (p < 0.001) and 3-month follow-up (p < 0.0001); the within-group effect size between baseline and 3-month follow-up IBS-SSS scores was large (d = 1.14) and 63.6% experienced a clinically meaningful improvement (ie, ≥50-point IBS-SSS score reduction). GI-specific anxiety symptoms and cognitions significantly improved at 2-month follow-up, as did unhelpful IBS safety behaviors. Additionally, clinically meaningful improvement was observed in depressive and anxiety symptoms at 3-month follow-up among participants with symptoms above the clinical threshold (ie, PHQ-9 ≥ 10 and GAD-7 ≥ 10, respectively) at baseline. CONCLUSIONS & INFERENCES These preliminary findings warrant a larger trial to investigate an unguided, web-based CBT for IBS symptom management that is powered to detect between-group treatment effects.
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Affiliation(s)
| | | | | | - Miranda A L van Tilburg
- College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC, USA.,Department of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,School of Social Work, University of Washington, Seattle, WA, USA
| | - Rona L Levy
- School of Social Work, University of Washington, Seattle, WA, USA
| | - Megan Oser
- Mahana Therapeutics, Inc, San Francisco, CA, USA
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Peppermint Oil Treatment for Irritable Bowel Syndrome: A Randomized Placebo-Controlled Trial. Am J Gastroenterol 2021; 116:2279-2285. [PMID: 34319275 DOI: 10.14309/ajg.0000000000001395] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Peppermint oil is often used to treat irritable bowel syndrome (IBS); however, the overall quality of previous studies is low, and findings have been heterogeneous. This study aimed to compare the effects of peppermint oil vs placebo in relieving IBS symptoms. METHODS In a 6-week, randomized, double-blind, placebo-controlled trial at a single academic center in the United States, individuals diagnosed with IBS (Rome IV criteria), with moderate to severe symptoms based on the IBS Severity Scoring System (IBS-SSS score ≥175), were randomized to enteric-coated peppermint oil 180 mg 3 times daily vs placebo in a 1:2 ratio. The primary outcome was mean change in IBS-SSS scores from baseline to 6-week endpoint. RESULTS A modified intent-to-treat analysis revealed that there were substantial mean improvements from baseline to 6-week endpoint in the main outcome measure (IBS-SSS) for both peppermint oil (90.8, SD = 75.3) and placebo (100.3, SD = 99.6). Although the peppermint oil group reported numerically lower improvement than the placebo group, the effect size was small (d = -0.11), and the difference between the groups was not statistically significant (P = 0.97). Similarly, both groups reported substantial improvements on the secondary endpoints; but again, there were no statistically significant differences between the groups on any of the secondary measures. Sensitivity analyses using multiple imputation to replace missing data produced similar results and revealed no significant differences between peppermint oil and placebo on any outcome measure. DISCUSSION Peppermint oil and placebo both showed clinically meaningful improvement in IBS symptoms. However, there were no significant differences between the groups. Further large, rigorous trials are needed to evaluate the role of peppermint oil for the treatment of IBS.
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93
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Multiunit In Vitro Colon Model for the Evaluation of Prebiotic Potential of a Fiber Plus D-Limonene Food Supplement. Foods 2021; 10:foods10102371. [PMID: 34681420 PMCID: PMC8535099 DOI: 10.3390/foods10102371] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 12/12/2022] Open
Abstract
The search for new fiber supplements that can claim to be "prebiotic" is expanding fast, as the role of prebiotics and intestinal microbiota in well-being has been well established. This work explored the prebiotic potential of a novel fiber plus D-Limonene supplement (FLS) in comparison to fructooligosaccharides (FOS) over distal colonic fermentation with the in vitro model MICODE (multi-unit in vitro colon gut model). During fermentation, volatilome characterization and core microbiota quantifications were performed, then correlations among volatiles and microbes were interpreted. The results indicated that FLS generated positive effects on the host gut model, determining: (i) eubiosis; (ii) increased abundance of beneficial bacteria, as Bifidobacteriaceae; (iii) production of beneficial compounds, as n-Decanoic acid; (iv) reduction in detrimental bacteria, as Enterobaceteriaceae; (v) reduction in detrimental compounds, as skatole. The approach that we followed permitted us to describe the prebiotic potential of FLS and its ability to steadily maintain the metabolism of colon microbiota over time. This aspect is two-faced and should be investigated further because if a fast microbial turnover and production of beneficial compounds is a hallmark of a prebiotic, the ability to reduce microbiota changes and to reduce imbalances in the productions of microbial metabolites could be an added value to FLS. In fact, it has been recently demonstrated that these aspects could serve as an adjuvant in metabolic disorders and cognitive decline.
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94
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Watkins JW, Lewis ZB. Diagnoses of Exclusion in the Workup of Abdominal Complaints. Emerg Med Clin North Am 2021; 39:851-863. [PMID: 34600642 DOI: 10.1016/j.emc.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abdominal pain is a common complaint in the emergency department, comprising 8.8% of all visits. Despite advances in medicine and imaging, 20% to 30% of patients still leave the department without a definitive diagnosis, whichhis can be both distressing for patients and unsatisfying for providers. Diagnoses of exclusion can be perilous, and their application should be carefully considered in order to not overlook more emergent complaints. However, a working knowledge of diagnoses of exclusion can guide therapeutics and specialty referrals that can ultimately provide answers and relief to a patient population often at odds with available information and expectations.
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Affiliation(s)
- Joseph Wesley Watkins
- University of Arkansas for Medical Sciences, 4301 West Markham Street Slot 584, Little Rock, AR 72205, USA.
| | - Zachary Bert Lewis
- University of Arkansas for Medical Sciences, 4301 West Markham Street Slot 584, Little Rock, AR 72205, USA
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95
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Patel NV. "Let Food Be Thy Medicine": Diet and Supplements in Irritable Bowel Syndrome. Clin Exp Gastroenterol 2021; 14:377-384. [PMID: 34588791 PMCID: PMC8473929 DOI: 10.2147/ceg.s321054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/11/2021] [Indexed: 12/12/2022] Open
Abstract
Overview: The purpose of this review is to introduce options for dietary therapies and supplements for the treatment of irritable bowel syndrome (IBS). IBS is a common condition with heterogeneity in pathogenesis and clinical presentation. Current treatment options are targeted at symptom relief with medications. Patients naturally pursue dietary modifications when dealing with symptoms. Dietary therapy for IBS has been poorly studied in the past; however, newer evidence suggests the use of certain diets, such as the low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet, as an intervention in patients with IBS for symptom improvement. Exclusion strategies are frequently tried, such as gluten restriction or lactose avoidance, but lack quality evidence behind their use. Additionally, supplements, such as fiber, probiotics, and peppermint oil, have also been used for IBS with more recent data suggesting the use of these supplements with specific caveats.
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Affiliation(s)
- Neha V Patel
- Digestive and Liver Diseases, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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96
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Sturkenboom R, Keszthelyi D, Brandts L, Weerts ZZRM, Snijkers JTW, Masclee AAM, Essers BAB. The estimation of a preference-based single index for the IBS-QoL by mapping to the EQ-5D-5L in patients with irritable bowel syndrome. Qual Life Res 2021; 31:1209-1221. [PMID: 34546554 PMCID: PMC8960586 DOI: 10.1007/s11136-021-02995-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/17/2022]
Abstract
Purpose The Irritable Bowel Syndrome Quality of Life (IBS-QoL) questionnaire is a commonly used and validated IBS-specific QoL instrument. However, this questionnaire is in contrast to the EQ-5D-5L, not preference-based and as such does not allow calculation of QALYs. The objective of this study was to describe the convergent- and known-group validity of both questionnaires and to develop a mapping algorithm from EQ-5D-5L which enable IBS-QoL scores to be transformed into utility scores for use in economic evaluations. Methods We used data from two multicenter randomized clinical trials, which represented the estimation and external validation dataset. The convergent validity was investigated by examining correlations between the EQ-5D-5L and IBS-QoL and the known-group validity by calculating effect sizes. Ordinary least squares (OLS), censored least absolute deviations (CLAD), and mixture models were used in this mapping approach. Results 283 IBS patients were included (n = 189 vs. n = 84). Mean IBS-QoL score was 71.13 (SD 15.66) and mean EQ-5D-5L utility score was 0.73 (SD 0.19). The overall sensitivity of the IBS-QoL and EQ-5D-5L to discriminate between patient and disease characteristics was similar. CLAD model 4, containing the total IBS-QoL score and squared IBS-SSS (IBS severity scoring system), was chosen as the most appropriate model to transform IBS-QoL scores into EQ-5D-5L utility scores. Conclusion This study reports the development of an algorithm where the condition-specific questionnaire IBS-QoL can be used to calculate utility values for use in economic evaluations. Including a clinical measure, IBS-SSS, in the model improved the performance of the algorithm. Supplementary Information The online version contains supplementary material available at 10.1007/s11136-021-02995-y.
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Affiliation(s)
- Rosel Sturkenboom
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands. .,Department of Clinical Epidemiology and Medical Technology Assessment, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Daniel Keszthelyi
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Zsa Zsa R M Weerts
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Johanna T W Snijkers
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Ad A M Masclee
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Brigitte A B Essers
- Department of Clinical Epidemiology and Medical Technology Assessment, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
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Medical Therapies for Diarrhea-Predominant Irritable Bowel Syndrome. Gastroenterol Clin North Am 2021; 50:611-637. [PMID: 34304791 DOI: 10.1016/j.gtc.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Diarrhea-predominant irritable bowel syndrome is a common functional gastrointestinal disorder that manifests with abdominal pain and diarrheal bowel patterns, without structural explanation. Diarrhea-predominant irritable bowel syndrome is a heterogeneous condition resulting from diverse pathophysiologic processes. Treatment strategies with varied mechanisms of action are beneficial in its management. The clinician must become familiar with a multi-dimensional approach to irritable bowel syndrome. The 3 approved medications are central to disease management. Effective treatment uses off-label medications and emerging therapies and a growing number of over-the-counter and supplemental agents to optimize symptom improvement for the patient with diarrhea-predominant irritable bowel syndrome.
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98
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Pérez de Arce E, Quera R, Quigley EMM. The Dilemma of Persistent Irritable Bowel Syndrome Symptoms in Patients with Quiescent Inflammatory Bowel Disease. Gastroenterol Clin North Am 2021; 50:689-711. [PMID: 34304795 DOI: 10.1016/j.gtc.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome and inflammatory bowel disease differ in their natural evolution, etiopathogenesis, diagnostic criteria, and therapeutic approach. However, recent evidence has suggested some similarities in mechanisms underlying symptom development and progression. There is a relevant role for alterations in the microbiome-brain-gut axis in both diseases. The presence of irritable bowel syndrome symptoms in patients with quiescent inflammatory bowel disease is common in clinical practice. To determine the cause of irritable bowel syndrome symptoms in patients with quiescent inflammatory bowel disease is a clinical challenge. This review aims to illustrate possible causes and solutions for these patients.
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Affiliation(s)
- Edith Pérez de Arce
- Department of Medicine, Division of Gastroenterology, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, Independencia, Región Metropolitana, Santiago, Chile
| | - Rodrigo Quera
- Division of Gastroenterology, Inflammatory Bowel Disease Program, Clínica Universidad de los Andes, Estoril 450, Las Condes, Región Metropolitana, Santiago, Chile
| | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX, USA.
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99
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Jagielski CH, Riehl ME. Behavioral Strategies for Irritable Bowel Syndrome: Brain-Gut or Gut-Brain? Gastroenterol Clin North Am 2021; 50:581-593. [PMID: 34304789 DOI: 10.1016/j.gtc.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction (DGBI) that is associated with significant physical, emotional, and occupational burden. Factors such as early life stress, sleep disruption, maladaptive coping strategies, symptom hypervigilance, and visceral hypersensitivity negatively affect gut-brain communication and increase the likelihood of developing IBS or worsen IBS severity. Behavioral strategies, such as cognitive behavioral therapy, gut-directed hypnosis, and mindfulness-based treatments, have shown benefit in improving gastrointestinal (GI)-specific quality of life, as well as reducing GI symptoms. Partnering with a GI-specific mental health provider can assist gastroenterologists in providing comprehensive treatment of IBS and other DGBIs.
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Affiliation(s)
- Christina H Jagielski
- Internal Medicine-Gastroenterology, Michigan Medicine, 380 Parkland Plaza, Ann Arbor, MI 48103, USA.
| | - Megan E Riehl
- Internal Medicine-Gastroenterology, Michigan Medicine, 3912 Taubman Center, SPC 5362, Suite 3436, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5362, USA
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100
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