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Krouwel M, Farley A, Greenfield S, Ismail T, Jolly K. Systematic review, meta-analysis with subgroup analysis of hypnotherapy for irritable bowel syndrome, effect of intervention characteristics. Complement Ther Med 2021; 57:102672. [PMID: 33508441 DOI: 10.1016/j.ctim.2021.102672] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/17/2020] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hypnotherapy has been shown to be effective at relieving global gastrointestinal symptoms (GGS) in irritable bowel syndrome (IBS). This study examines the impact of hypnotherapy delivery and participant characteristics on IBS outcomes. METHODS This systematic review searched CINAHL, Cochrane Library, Conference Citation Index, Embase, PubMed, PsycARTICLES, PsychINFO, Science Citation index-expanded, Social Science Citation Index. Titles and abstracts, then full-text articles were screened against inclusion criteria: trials with a concurrent comparator of hypnotherapy in adults with IBS diagnosed using Manning or ROME criteria, which provided symptom data. Included studies were extracted and assessed for bias using Cochrane Collaboration 2011 guidance. Random-effects meta-analysis was conducted with sub-group analysis to assess the impact of delivery characteristics on outcomes. RESULTS Twelve trials were included, 7 in the meta-analyses. Hypnotherapy reduced the risk of GGS, but this was not statistically significant, (standardised mean difference (SMD) 0.24, [-0.06, 0.54], I2 66 %). Higher frequency of sessions (≥1/week) reduced GGS (SMD 0.45 [0.23,0.67] I2 0 %), as did higher volumes of intervention (≥8 sessions with ≥6 h of contact) (SMD 0.51 [0.27,0.76] I2 0 %) and group interventions (SMD 0.45 [0.03, 0.88] I2 62 %). Only volume of intervention produced a significant effect between the subgroups. CONCLUSION This review suggests that high volume hypnotherapy is more beneficial than low and should be adopted for GDH. Both high frequency and group interventions are effective in reducing GGS in IBS. However, the sample size is small and more studies are needed to confirm this.
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Affiliation(s)
- Matthew Krouwel
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
| | - Amanda Farley
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Tariq Ismail
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
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152
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Shah ED, Salwen-Deremer JK, Gibson PR, Muir JG, Eswaran S, Chey WD. Pharmacologic, Dietary, and Psychological Treatments for Irritable Bowel Syndrome With Constipation: Cost Utility Analysis. MDM Policy Pract 2021; 6:2381468320978417. [PMID: 33521290 PMCID: PMC7818007 DOI: 10.1177/2381468320978417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/28/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction. Irritable bowel syndrome (IBS) is the most common gastroenterology referral and one of the most common gastrointestinal complaints in primary care. We performed a cost-utility analysis of the most common treatments available in general practice for IBS with constipation (IBS-C), the most expensive IBS subtype. Methods. We developed a decision analytic model evaluating guideline-recommended and Food and Drug Administration-approved drugs, supplements, and dietary/psychological interventions. Model inputs were derived from "global symptom improvement" outcomes in systematic reviews of clinical trials. Costs were derived from national datasets. Analysis was performed with a 1-year time horizon from patient and payer perspectives. We analyzed a prototypical managed-care health plan with no cost-sharing to the patient. Results. From a payer perspective, global IBS treatments (including low FODMAP, cognitive behavioral therapy [CBT], neuromodulators), which are not specific to the IBS-C bowel subtype were less expensive than on-label prescription drug treatments. From a patient perspective, on-label prescription drug treatment with linaclotide was the least expensive treatment strategy. Drug prices and costs to manage untreated IBS-C were most important determinants of payer treatment preferences. Effects of treatment on missed work-days and need for repeated appointments to complete treatment were the most important determinants of treatment preference to patients. Discussion. Due mostly to prescription drug prices, neuromodulators, low FODMAP, and CBT appear cost-effective compared to on-label drug treatments from a payer perspective in cost-utility analysis. These findings may explain common treatment barriers in clinical practice.
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Affiliation(s)
- Eric D. Shah
- Eric D. Shah, Center for Gastrointestinal
Motility, Esophageal, and Swallowing Disorders, Dartmouth-Hitchcock Medical
Center, One Medical Center Drive, Lebanon, NH 03766, USA; telephone: (603)
650-5261 ()
| | - 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, Victoria, Australia
| | - Jane G. Muir
- Department of Gastroenterology, Central Clinical
School, Monash University, Melbourne, Victoria, 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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153
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Chey WD, Keefer L, Whelan K, Gibson PR. Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome. Gastroenterology 2021; 160:47-62. [PMID: 33091411 DOI: 10.1053/j.gastro.2020.06.099] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/08/2020] [Accepted: 06/06/2020] [Indexed: 02/06/2023]
Abstract
Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan.
| | | | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, United Kingdom
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154
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Mars RAT, Frith M, Kashyap PC. Functional Gastrointestinal Disorders and the Microbiome-What Is the Best Strategy for Moving Microbiome-based Therapies for Functional Gastrointestinal Disorders into the Clinic? Gastroenterology 2021; 160:538-555. [PMID: 33253687 PMCID: PMC8575137 DOI: 10.1053/j.gastro.2020.10.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 02/07/2023]
Abstract
There have been numerous human studies reporting associations between the intestinal microbiome and functional gastrointestinal disorders (FGIDs), and independently animal studies have explored microbiome-driven mechanisms underlying FGIDs. However, there is often a disconnect between human and animal studies, which hampers translation of microbiome findings to the clinic. Changes in the microbiota composition of patients with FGIDs are generally subtle, whereas changes in microbial function, reflected in the fecal metabolome, appear to be more precise indicators of disease subtype-specific mechanisms. Although we have made significant progress in characterizing the microbiome, to effectively translate microbiome science in a timely manner, we need concurrent and iterative longitudinal studies in humans and animals to determine the precise microbial functions that can be targeted to address specific pathophysiological processes in FGIDs. A systems approach integrating multiple data layers rather than evaluating individual data layers of symptoms, physiological changes, or -omics data in isolation will allow for validation of mechanistic insights from animal studies while also allowing new discovery. Patient stratification for clinical trials based on functional microbiome alterations and/or pathophysiological measurements may allow for more accurate determination of efficacy of individual microbiome-targeted interventions designed to correct an underlying abnormality. In this review, we outline current approaches and knowledge, and identify gaps, to provide a potential roadmap for accelerating translation of microbiome science toward microbiome-targeted personalized treatments for FGIDs.
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Affiliation(s)
- Ruben A T Mars
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Mary Frith
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Purna C Kashyap
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota.
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155
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Shah SL, Janisch NH, Crowell M, Lacy BE. Patients With Irritable Bowel Syndrome Are Willing to Take Substantial Medication Risks for Symptom Relief. Clin Gastroenterol Hepatol 2021; 19:80-86. [PMID: 32289536 DOI: 10.1016/j.cgh.2020.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder for which patients take significant risks to ameliorate symptoms. Unfortunately, there is no cure for IBS. We assessed the willingness of patients with IBS to take medication risks and the costs they would pay to improve symptoms. METHODS We mailed a survey on medication risk to patients with IBS who met the Rome IV criteria. The survey collected data on patient demographics, symptoms, medication use, prior medication-averse events, and pain catastrophization. A standard gamble evaluated respondents' willingness to take medication risks, and a willingness-to-pay set of questions quantified maximal spending on a hypothetical medication to treat IBS. RESULTS Among respondents (n = 215; 81.8% female; mean age, 57 y) the average duration of IBS symptoms was 17.7 years. Patients whose predominant symptom was severe diarrhea (diarrhea-predominant IBS) reported accepting a mean 10.2% ± 15.7% risk of sudden death for a 99% chance of cure. Pain catastrophizing scale scores were not associated with an increased likelihood of taking medication risks. Patients with IBS would be willing to pay an average amount of $73 per month (if annual income was <$75,000) and $197 per month (if annual income was >$75,000) for a medication that would resolve their pain. CONCLUSIONS In a survey of 215 patients with IBS, we found that patients with diarrhea-predominant IBS are willing to take extraordinary risks to improve their symptoms, whereas patients with IBS and pain catastrophization are not. Clinician understanding of patients' willingness to take medication risks might help them guide their patients through complex therapeutic options.
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Affiliation(s)
- Shawn L Shah
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York.
| | - Nigeen H Janisch
- Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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156
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ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastroenterol 2021; 116:17-44. [PMID: 33315591 DOI: 10.14309/ajg.0000000000001036] [Citation(s) in RCA: 350] [Impact Index Per Article: 116.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.
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157
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Andrews CN, Bradette M. Diarrhea-Predominant Irritable Bowel Syndrome: Medical Management Update. J Can Assoc Gastroenterol 2020; 3:e37-e48. [PMID: 33241185 PMCID: PMC7678738 DOI: 10.1093/jcag/gwz034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 10/29/2019] [Indexed: 11/24/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder, which impacts the quality of life, work productivity and social activities of patients. Diarrhea-predominant IBS (IBS-D) is one of several subtypes, and accounts for approximately one third of all cases. Currently available treatments are typically unable to alleviate the cardinal symptoms of IBS-D, including abdominal pain and diarrhea, and a clinical unmet need remains for an effective treatment which simultaneously relieves multiple symptoms. Patients may benefit from a multipronged, individualized approach, including dietary modifications, and psychological and pharmacological therapies. The aim of this review is to provide an update on the available and upcoming treatment options for IBS-D in Canada, with reference to the recently updated Canadian IBS consensus guidelines. Initial treatment approaches include lifestyle modifications, dietary modifications, and non-prescription therapies such as peppermint oil. While some medications such as tricyclic antidepressants are also used to treat IBS-D symptoms, eluxadoline and rifaximin are the only two pharmacological therapies approved for the treatment of IBS-D in Canada. Key clinical trial data for the currently available pharmacological options are presented to provide an overview of the efficacy and safety of these agents.
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Affiliation(s)
| | - Marc Bradette
- Division of Gastroenterology, Centre Hospitalier Universitaire de Québec (CHU), Laval University, Québec, Québec, Canada
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158
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Farmer AD, Wood E, Ruffle JK. An approach to the care of patients with irritable bowel syndrome. CMAJ 2020; 192:E275-E282. [PMID: 32179536 DOI: 10.1503/cmaj.190716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Adam D Farmer
- Department of Gastroenterology (Farmer, Wood), University Hospitals of North Midlands, Stoke-on-Trent, UK; Institute of Applied Clinical Science (Farmer), University of Keele, Keele, Staffordshire, UK; Centre for Neuroscience, Surgery and Trauma (Farmer, Ruffle), Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Emma Wood
- Department of Gastroenterology (Farmer, Wood), University Hospitals of North Midlands, Stoke-on-Trent, UK; Institute of Applied Clinical Science (Farmer), University of Keele, Keele, Staffordshire, UK; Centre for Neuroscience, Surgery and Trauma (Farmer, Ruffle), Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - James K Ruffle
- Department of Gastroenterology (Farmer, Wood), University Hospitals of North Midlands, Stoke-on-Trent, UK; Institute of Applied Clinical Science (Farmer), University of Keele, Keele, Staffordshire, UK; Centre for Neuroscience, Surgery and Trauma (Farmer, Ruffle), Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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159
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Ford AC, Sperber AD, Corsetti M, Camilleri M. Irritable bowel syndrome. Lancet 2020; 396:1675-1688. [PMID: 33049223 DOI: 10.1016/s0140-6736(20)31548-8] [Citation(s) in RCA: 347] [Impact Index Per Article: 86.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/26/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome is a functional gastrointestinal disorder with symptoms including abdominal pain associated with a change in stool form or frequency. The condition affects between 5% and 10% of otherwise healthy individuals at any one point in time and, in most people, runs a relapsing and remitting course. The best described risk factor is acute enteric infection, but irritable bowel syndrome is also more common in people with psychological comorbidity and in young adult women than in the rest of the general population. The pathophysiology of irritable bowel syndrome is incompletely understood, but it is well established that there is disordered communication between the gut and the brain, leading to motility disturbances, visceral hypersensitivity, and altered CNS processing. Other less reproducible mechanisms might include genetic associations, alterations in gastrointestinal microbiota, and disturbances in mucosal and immune function. In most people, diagnosis can be made on the basis of clinical history with limited and judicious use of investigations, unless alarm symptoms such as weight loss or rectal bleeding are present, or there is a family history of inflammatory bowel disease or coeliac disease. Once the diagnosis is made, an empathetic approach is key and can improve quality of life and symptoms, and reduce health-care expenditure. The mainstays of treatment include patient education about the condition, dietary changes, soluble fibre, and antispasmodic drugs. Other treatments tend to be reserved for people with severe symptoms and include central neuromodulators, intestinal secretagogues, drugs acting on opioid or 5-HT receptors, or minimally absorbed antibiotics (all of which are selected according to predominant bowel habit), as well as psychological therapies. Increased understanding of the pathophysiology of irritable bowel syndrome in the past 10 years has led to a healthy pipeline of novel drugs in development.
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Affiliation(s)
- 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.
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Maura Corsetti
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, MN, USA
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160
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Zhan K, Zheng H, Li J, Wu H, Qin S, Luo L, Huang S. Gut Microbiota-Bile Acid Crosstalk in Diarrhea-Irritable Bowel Syndrome. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3828249. [PMID: 33274207 PMCID: PMC7676935 DOI: 10.1155/2020/3828249] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
The occurrence of diarrhea-predominant irritable bowel syndrome (IBS-D) is the result of multiple factors, and its pathogenesis has not yet been clarified. Emerging evidence indicates abnormal changes in gut microbiota and bile acid (BA) metabolism have a close relationship with IBS-D. Gut microbiota is involved in the secondary BA production via deconjugation, 7α-dehydroxylation, oxidation, epimerization, desulfation, and esterification reactions respectively. Changes in the composition and quantity of gut microbiota have an important impact on the metabolism of BAs, which can lead to the occurrence of gastrointestinal diseases. BAs, synthesized in the hepatocytes, play an important role in maintaining the homeostasis of gut microbiota and the balance of glucose and lipid metabolism. In consideration of the complex biological functional connections among gut microbiota, BAs, and IBS-D, it is urgent to review the latest research progress in this field. In this review, we summarized the alterations of gut microbiota in IBS-D and discussed the mechanistic connections between gut microbiota and BA metabolism in IBS-D, which may be involved in activating two important bile acid receptors, G-protein coupled bile acid receptor 1 (TGR5) and farnesoid X receptor (FXR). We also highlight the strategies of prevention and treatment of IBS-D via regulating gut microbiota-bile acid axis, including probiotics, fecal microbiota transplantation (FMT), cholestyramine, and the cutting-edge technology about bacteria genetic engineering.
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Affiliation(s)
- Kai Zhan
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Huan Zheng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Jianqing Li
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Haomeng Wu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Shumin Qin
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Lei Luo
- Department of Gastroenterology, The Second People's Hospital of China Three Gorges University, Yichang 443000, China
| | - Shaogang Huang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510000, China
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161
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Abstract
Functional bowel disorders refer to disorders of gut-brain interaction that affect the intestinal tract. Irritable bowel syndrome (IBS) is the most common functional bowel disorder and affects individuals regardless of age and gender. It can result in impaired quality of life and significant health care utilization and is therefore important to recognize and manage. The diagnosis of IBS is based on clinical symptoms. IBS is categorized based on predominant bowel habit (constipation, diarrhea, mixed, or unclassified), and the treatment of IBS is individually tailored based on subtype and symptom severity.
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162
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Screening dietary fibres for fermentation characteristics and metabolic profiles using a rapid in vitro approach: implications for irritable bowel syndrome. Br J Nutr 2020; 126:208-218. [PMID: 33028442 DOI: 10.1017/s0007114520003943] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The therapeutic value of specific fibres is partly dependent on their fermentation characteristics. Some fibres are rapidly degraded with the generation of gases that induce symptoms in patients with irritable bowel syndrome (IBS), while more slowly or non-fermentable fibres may be more suitable. More work is needed to profile a comprehensive range of fibres to determine suitability for IBS. Using a rapid in vitro fermentation model, gas production and metabolite profiles of a range of established and novel fibres were compared. Fibre substrates (n 15) were added to faecal slurries from three healthy donors for 4 h with gas production measured using real-time headspace sampling. Concentrations of SCFA and ammonia were analysed using GC and enzymatic assay, respectively. Gas production followed three patterns: rapid (≥60 ml/g over 4 h) for fructans, carrot fibre and maize-derived xylo-oligosaccharide (XOS); mild (30-60 ml/g) for partially hydrolysed guar gum, almond shell-derived XOS and one type of high-amylose resistant starch 2 (RS2) and minimal (no differences with blank controls) for methylcellulose, another high-amylose RS2, acetylated or butyrylated RS2, RS4, acacia gum and sugarcane bagasse. Gas production correlated positively with total SCFA (r 0·80, P < 0·001) and negatively with ammonia concentrations (r -0·68, P < 0·001). Proportions of specific SCFA varied: fermentation of carrot fibre, XOS and acetylated RS2 favoured acetate, while fructans favoured butyrate. Gas production and metabolite profiles differed between fibre types and within fibre classes over a physiologically relevant 4-h time course. Several fibres resisted rapid fermentation and may be candidates for clinical trials in IBS patients.
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163
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Keszthelyi D. Antidepressant use in gastroenterology: Overcoming hurdles. Neurogastroenterol Motil 2020; 32:e13982. [PMID: 32935408 DOI: 10.1111/nmo.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/14/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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164
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Shortcomings of Trials Assessing Antidepressants in the Management of Irritable Bowel Syndrome: A Critical Review. J Clin Med 2020; 9:jcm9092933. [PMID: 32932856 PMCID: PMC7564007 DOI: 10.3390/jcm9092933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/12/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a common disorder requiring complex, multidisciplinary management. Antidepressants are commonly used and recommended in guidelines for the treatment of patients with IBS. We assessed randomized controlled trials (RCTs) on antidepressants in patients with IBS, with specific attention to study design and data quality/reporting characteristics. Following a comprehensive search, data and RCT characteristics were systematically summarized. Fragility index, representing the number of positive “events” that the study relies on for its significance, was calculated. Eighteen RCTs were included. Overall, tricyclic antidepressants (TCAs), but not selective serotonin reuptake inhibitors (SSRIs), appeared to be efficacious in IBS. Eight studies reported on adverse events (AEs), which were significantly greater in patients receiving antidepressants versus placebo. The median (mean) fragility index of TCA trials was 0 (1.5). RCTs with positive results had significantly lower placebo rates (20.8%) versus negative studies (45.7%; p < 0.0001). RCTs exhibited limitations related to study design (sample size and blinding), data analysis (outcomes and placebo response), and data reporting (selective reporting of AEs and publication bias). Careful consideration of limitations of RCTs on antidepressants in IBS is warranted to formulate a safe and beneficial treatment regimen for patients with IBS.
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165
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Carco C, Young W, Gearry RB, Talley NJ, McNabb WC, Roy NC. Increasing Evidence That Irritable Bowel Syndrome and Functional Gastrointestinal Disorders Have a Microbial Pathogenesis. Front Cell Infect Microbiol 2020; 10:468. [PMID: 33014892 PMCID: PMC7509092 DOI: 10.3389/fcimb.2020.00468] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
The human gastrointestinal tract harbors most of the microbial cells inhabiting the body, collectively known as the microbiota. These microbes have several implications for the maintenance of structural integrity of the gastrointestinal mucosal barrier, immunomodulation, metabolism of nutrients, and protection against pathogens. Dysfunctions in these mechanisms are linked to a range of conditions in the gastrointestinal tract, including functional gastrointestinal disorders, ranging from irritable bowel syndrome, to functional constipation and functional diarrhea. Irritable bowel syndrome is characterized by chronic abdominal pain with changes in bowel habit in the absence of morphological changes. Despite the high prevalence of irritable bowel syndrome in the global population, the mechanisms responsible for this condition are poorly understood. Although alterations in the gastrointestinal microbiota, low-grade inflammation and immune activation have been implicated in the pathophysiology of functional gastrointestinal disorders, there is inconsistency between studies and a lack of consensus on what the exact role of the microbiota is, and how changes to it relate to these conditions. The complex interplay between host factors, such as microbial dysbiosis, immune activation, impaired epithelial barrier function and motility, and environmental factors, including diet, will be considered in this narrative review of the pathophysiology of functional gastrointestinal disorders.
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Affiliation(s)
- Caterina Carco
- School of Food and Advanced Technology, Massey University, Palmerston North, New Zealand.,Riddet Institute, Massey University, Palmerston North, New Zealand.,Food Nutrition and Health Team, AgResearch Grasslands, Palmerston North, New Zealand.,The High-Value Nutrition National Science Challenge, Auckland, New Zealand
| | - Wayne Young
- Riddet Institute, Massey University, Palmerston North, New Zealand.,Food Nutrition and Health Team, AgResearch Grasslands, Palmerston North, New Zealand.,The High-Value Nutrition National Science Challenge, Auckland, New Zealand
| | - Richard B Gearry
- The High-Value Nutrition National Science Challenge, Auckland, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Warren C McNabb
- Riddet Institute, Massey University, Palmerston North, New Zealand.,The High-Value Nutrition National Science Challenge, Auckland, New Zealand
| | - Nicole C Roy
- Riddet Institute, Massey University, Palmerston North, New Zealand.,The High-Value Nutrition National Science Challenge, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand.,Department of Human Nutrition, University of Otago, Dunedin, New Zealand
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166
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Vahora IS, Tsouklidis N, Kumar R, Soni R, Khan S. How Serotonin Level Fluctuation Affects the Effectiveness of Treatment in Irritable Bowel Syndrome. Cureus 2020; 12:e9871. [PMID: 32968548 PMCID: PMC7505258 DOI: 10.7759/cureus.9871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Irritable bowel syndrome (IBS) is one of the most commonly diagnosed functional gastrointestinal (GI) disorders. It affects both men and women. Enteric serotonin (5HT) is responsible for gut motility, secretion, visceral hypersensitivity, and inflammation. The serotonin reuptake transporter (SERT) maintains serotonin levels by regulating its reuptake. An increase in SERT expression causes a decrease in serotonin, which leads to IBS-C (irritable bowel syndrome, constipation-predominant), whereas a decrease in SERT transcription causes an increase in serotonin, which leads to IBS-D (irritable bowel syndrome, diarrhea-predominant). Some factors can alter SERT transcription, such as certain bacteria, inflammation, growth factor, and glucagon-like peptide-1. This shows that 5HT and SERT both have an important role in IBS pathophysiology so that it would be a better subject to target for the treatment aspect of IBS. 5HT3 receptor antagonists are advisable for IBS-D to block the excessive activity of serotonin at the 5HT3 receptor and reduce gut motility. For IBS-C, we prescribe 5HT4 receptor agonists, which promote gut motility. Also, the latest treatment approach, antidepressant drugs TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitors), are helpful by modulating serotonin levels in the gut. In this literature review, we found that serotonin is one of the main pathophysiological factors for IBS, and we can treat IBS by targeting serotonin function on gut motility.
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Affiliation(s)
- Ilmaben S Vahora
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nicholas Tsouklidis
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
| | - Rajat Kumar
- Ophthalmology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ravi Soni
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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167
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Black CJ, Thakur ER, Houghton LA, Quigley EMM, Moayyedi P, Ford AC. Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis. Gut 2020; 69:1441-1451. [PMID: 32276950 DOI: 10.1136/gutjnl-2020-321191] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES National guidelines for the management of irritable bowel syndrome (IBS) recommend that psychological therapies should be considered, but their relative efficacy is unknown, because there have been few head-to-head trials. We performed a systematic review and network meta-analysis to try to resolve this uncertainty. DESIGN We searched the medical literature through January 2020 for randomised controlled trials (RCTs) assessing efficacy of psychological therapies for adults with IBS, compared with each other, or a control intervention. Trials reported a dichotomous assessment of symptom status after completion of therapy. We pooled data using a random effects model. Efficacy was reported as a pooled relative risk (RR) of remaining symptomatic, with a 95% CI to summarise efficacy of each comparison tested, and ranked by therapy according to P score. RESULTS We identified 41 eligible RCTs, containing 4072 participants. After completion of therapy, the psychological interventions with the largest numbers of trials, and patients recruited, demonstrating efficacy included self-administered or minimal contact cognitive behavioural therapy (CBT) (RR 0.61; 95% CI 0.45 to 0.83, P score 0.66), face-to-face CBT (RR 0.62; 95% CI 0.48 to 0.80, P score 0.65) and gut-directed hypnotherapy (RR 0.67; 95% CI 0.49 to 0.91, P score 0.57). After completion of therapy, among trials recruiting only patients with refractory symptoms, group CBT and gut-directed hypnotherapy were more efficacious than either education and/or support or routine care, and CBT via the telephone, contingency management, CBT via the internet and dynamic psychotherapy were all superior to routine care. Risk of bias of trials was high, with evidence of funnel plot asymmetry; the efficacy of psychological therapies is therefore likely to have been overestimated. CONCLUSIONS Several psychological therapies are efficacious for IBS, although none were superior to another. CBT-based interventions and gut-directed hypnotherapy had the largest evidence base and were the most efficacious long term. TRIAL REGISTRATION NUMBER The study protocol was published on the PROSPERO international prospective register of systematic reviews (registration number CRD 42020163246).
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, West Yorkshire, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, West Yorkshire, UK
| | - Elyse R Thakur
- Department of Psychiatry and Behavioural Sciences, Baylor College of Medicine, Houston, Texas, USA.,Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, North Carolina, USA
| | - Lesley A Houghton
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, West Yorkshire, UK
| | - Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, West Yorkshire, UK .,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, West Yorkshire, UK
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168
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Black CJ, Yiannakou Y, Houghton LA, Shuweihdi F, West R, Guthrie E, Ford AC. Anxiety-related factors associated with symptom severity in irritable bowel syndrome. Neurogastroenterol Motil 2020; 32:e13872. [PMID: 32396247 DOI: 10.1111/nmo.13872] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/10/2020] [Accepted: 04/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrointestinal symptom-specific anxiety and somatization have both been associated with higher symptom severity in patients with irritable bowel syndrome (IBS); however, this relationship has not been explored fully. Moreover, the performance of the visceral sensitivity index (VSI) for measuring gastrointestinal symptom-specific anxiety has not been examined in a UK population. We conducted a cross-sectional survey to examine these issues. METHODS Gastrointestinal symptom-specific anxiety was measured using the VSI, and somatization was measured via the patient health questionnaire-12 (PHQ-12) in adults from the UK community with Rome IV-defined IBS. Exploratory factor analysis was performed on the VSI, prior to subsequent analyses, to establish its factor structure. Multiple regression analysis was used to determine the relationship between demographic features, different factors of the VSI, somatization, and IBS symptom severity. KEY RESULTS A total of 811 individuals with IBS provided complete data. Factor analysis of the VSI revealed a three-factor structure, accounting for 47% of the variance. The first of these VSI factors and the PHQ-12 were both strongly and independently associated with IBS symptom severity, for the group as a whole and for all four IBS subtypes. Most VSI items concerned with overt gastrointestinal symptom-specific anxiety loaded onto the other two VSI factors that were not associated with symptom severity. CONCLUSIONS AND INFERENCES The factor structure of the VSI requires further investigation. Our findings cast doubt on the central role of gastrointestinal symptom-specific anxiety as a driver for symptom severity in IBS. Awareness of both gastrointestinal and extra-intestinal symptoms, however, is strongly associated with symptom severity.
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Yan Yiannakou
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Lesley A Houghton
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Farag Shuweihdi
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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169
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Chey WD. Integrated care for disorders of gut-brain interaction. Lancet Gastroenterol Hepatol 2020; 5:876-877. [PMID: 32679041 DOI: 10.1016/s2468-1253(20)30235-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022]
Affiliation(s)
- William D Chey
- Division of Gastroenterology, Taubman Center, Ann Arbor, MI 48109, USA.
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170
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Song J, Yang L, Su S, Piao MY, Li BL, Liang LX, Zuo GW, Tang ZM, Long YQ, Chen XL, Dai N, Mo JL, Yu Y, Yu WY, Zhang M, Wang RQ, Chen J, Hou XH. The Diagnosis Performance of the TCM Syndromes of Irritable Bowel Syndrome by Gastroenterologists Based on Modified Simple Criteria Compared to TCM Practitioners: A Prospective, Multicenter Preliminary Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2020; 2020:9507674. [PMID: 32695213 PMCID: PMC7368204 DOI: 10.1155/2020/9507674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/23/2020] [Accepted: 06/13/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Traditional Chinese medicine (TCM) including Chinese patent medicine has been widely used to treat irritable bowel syndrome (IBS). Syndrome differentiation is the essence of TCM. However, the diagnostic ability of gastroenterologists to detect TCM syndromes in IBS in China remains unknown. The aim of this study was to investigate the ability of gastroenterologists to diagnose the TCM syndromes of IBS based on modified simple criteria compared with TCM practitioners. METHODS Patients meeting the Rome III criteria for IBS-D or IBS-C were recruited from six tertiary referral centers between January 2016 and December 2017. After learning the diagnosis criteria of the TCM syndromes in IBS, gastroenterologists first diagnosed the syndromes of the enrolled patients. Subsequently, the patients were diagnosed by TCM practitioners. The rate of agreement between the gastroenterologists and TCM practitioners was analyzed. In addition, demographic data and the distribution of TCM syndrome types in IBS were also analyzed. RESULTS A total of 178 patients (93 males and 85 females), including 131 patients with IBS-D and 47 patients with IBS-C, were enrolled in this study. The rate of agreement of the syndrome diagnosis between the gastroenterologists and TCM practitioners was 84.3%. The diagnosis consistency rates among IBS-D patients and IBS-C patients were 87.0% and 76.5%, respectively. The most common TCM syndrome type in IBS-D patients was liver depression and spleen deficiency syndrome (27.5%), followed by spleen-yang deficiency syndrome (19.8%). Dryness and heat in intestine syndrome was the most common TCM syndrome in IBS-C patients (57.4%). CONCLUSIONS Gastroenterologists had good diagnostic agreement with TCM practitioners for diagnosing TCM syndrome types in IBS after learning the diagnostic criteria. This knowledge can aid gastroenterologists in selecting suitable Chinese patent medicine to treat IBS.
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Affiliation(s)
- Jun Song
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan 430022, China
| | - Ling Yang
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan 430022, China
| | - Shuai Su
- Department of Gastroenterology, Tianjin Medical University General Hospital, Tianjin 30052, China
| | - Mei-Yu Piao
- Department of Gastroenterology, Tianjin Medical University General Hospital, Tianjin 30052, China
| | - Bao-Li Li
- Department of Traditional Chinese Medicine, Tianjin Medical University General Hospital, Tianjin 30052, China
| | - Lie-Xin Liang
- Department of Digestion, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, China
| | - Guo-Wen Zuo
- Department of Digestion, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, China
| | - Zhi-Min Tang
- Department of Traditional Chinese Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, China
| | - Yan-qin Long
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310020, China
| | - Xiao-Li Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310020, China
| | - Ning Dai
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310020, China
| | - Jian-Ling Mo
- Department of Traditional Chinese Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310020, China
| | - Yue Yu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 230001, China
| | - Wen-Yong Yu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 230001, China
| | - Mei Zhang
- Department of Chinese-Western Medicine Integrative Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei 230001, China
| | - Rong-Quan Wang
- Department of Gastroenterology, The Southwest Hospital of Third Military Medical University, Chongqing 400038, China
| | - Jing Chen
- Department of Traditional Chinese Medicine, The Southwest Hospital of Third Military Medical University, Chongqing 400038, China
| | - Xiao-Hua Hou
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan 430022, China
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171
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Black CJ, Moayyedi P, Quigley EMM, Ford AC. Peppermint Oil in Irritable Bowel Syndrome. Gastroenterology 2020; 159:395-396. [PMID: 32289372 DOI: 10.1053/j.gastro.2019.09.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital and, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Paul Moayyedi
- Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, Ontario, Canada
| | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Lynda K. and David M. Underwood Center for Digestive Disorders, Houston Methodist Hospital and, Weill Cornell Medical College, Houston, Texas
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital and, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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172
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Moayyedi P, Simrén M, Bercik P. Evidence-based and mechanistic insights into exclusion diets for IBS. Nat Rev Gastroenterol Hepatol 2020; 17:406-413. [PMID: 32123377 DOI: 10.1038/s41575-020-0270-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/14/2022]
Abstract
Exclusion diets are becoming increasingly popular in the management of irritable bowel syndrome (IBS). Several mechanisms exist by which food items might cause gastrointestinal symptoms, such as direct osmotic effects of food in the gut lumen, changes to the gut microbiota and immune activation. These effects have been demonstrated in animal models and in human studies, particularly in the case of gluten-free diets and diets low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs). Indeed, randomized controlled trials (RCTs) suggest that gluten-free diets and low-FODMAP diets improve IBS symptoms, and guidelines recommend the latter approach for treating symptoms in some patients with IBS. Designing such RCTs is challenging as participants need to eat so an 'inert' placebo is not an option. Blinding is also an issue with these studies; in the future, new exclusion diets should not advertise what the diet consists of until it is proved to reduce symptoms. In this Review, we outline the advantages and disadvantages of each choice of control group and emphasize the importance of collecting mechanistic data (regarding direct effects of food on the gut lumen, changes in gut microbiota and intestinal inflammation) as well as symptom data in RCTs of exclusion diets in IBS.
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Affiliation(s)
- Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Premysl Bercik
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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173
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Black CJ, Ford AC. Best management of irritable bowel syndrome. Frontline Gastroenterol 2020; 12:303-315. [PMID: 34249316 PMCID: PMC8231425 DOI: 10.1136/flgastro-2019-101298] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 02/04/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction which can have a considerable impact on quality of life. Following diagnosis, timely and evidence-based management is vital to the care of patients with IBS, aiming to improve outcomes, and enhance patient satisfaction. Good communication is paramount, and clinicians should provide a clear explanation about the disorder, with a focus on exploring the patient's own beliefs about IBS, and a discussion of any concerns they may have. It should be emphasised that symptoms are often chronic, and that treatment, while aiming to improve symptoms, may not relieve them completely. Initial management should include simple lifestyle and dietary advice, discussion of the possible benefit of some probiotics, and, if this is unsuccessful, patients can be referred to a dietician for consideration of a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet. Antispasmodics and peppermint oil can be used first-line for the treatment of abdominal pain. If patients fail to respond, central neuromodulators can be used second-line; tricyclic antidepressants should be preferred. Loperamide and laxatives can be used first-line for treating diarrhoea and constipation, respectively. Patients with constipation who fail to respond to laxatives should be offered a trial of linaclotide. For patients with diarrhoea, the 5-hydroxytryptamine-3 receptor agonists alosetron and ramosetron appear to be the most effective second-line drugs. Where these are unavailable, ondansetron is a reasonable alternative. If medical treatment is unsuccessful, patients should be referred for psychological therapy, where available, if they are amenable to this. Cognitive behavioural therapy and gut-directed hypnotherapy are the psychological therapies with the largest evidence base.
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, West Yorkshire, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Alexander Charles Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, West Yorkshire, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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174
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Fox JC, Lipstein EA. Shared Decision Making in Gastroenterology: Challenges and Opportunities. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2020; 4:183-189. [PMID: 32280929 PMCID: PMC7139984 DOI: 10.1016/j.mayocpiqo.2019.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022] Open
Abstract
This article reviews the current uses of shared decision making in gastroenterology and discusses additional areas of opportunity for shared decision making, especially in the area of functional gastrointestinal disorders. PubMed, MEDLINE, and Cochrane library databases were searched for articles published during a 10-year period from January 1, 2007, through December 31, 2017. Search terms included shared decision making and gastroenterology, shared decision making in gastrointestinal disease, shared decision making in functional GI disorders, and shared decision making and irritable bowel syndrome. Studies were not included in this review when a health care professional other than a gastroenterologist was involved, eg, an article that reported shared decision making regarding the use of radiation therapy in a patient with advanced rectal cancer in which the health care professional helping to make the decision was an oncologist.
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Affiliation(s)
- Jean C Fox
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ellen A Lipstein
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, OH
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175
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Bassotti G. What can be done pharmacologically for a subject with severe refractory constipation-predominant irritable bowel syndrome? Expert Opin Pharmacother 2020; 21:617-618. [PMID: 31990590 DOI: 10.1080/14656566.2020.1718650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
- Gastroenterology Unit, Santa Maria della Misericordia Hospital, Perugia, Italy
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176
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Liu R, Staller K. Update on Eluxadoline for the Treatment of Irritable Bowel Syndrome with Diarrhea: Patient Selection and Perspectives. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:1391-1400. [PMID: 32308371 PMCID: PMC7153999 DOI: 10.2147/dddt.s216056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/09/2020] [Indexed: 12/15/2022]
Abstract
Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder characterized by chronic abdominal pain associated with changes in bowel habits. It is the most common GI problem seen by gastroenterologists. IBS is a heterogenous disorder encompassing a spectrum of underlying mechanisms and clinical presentations. The pathophysiology of diarrhea-predominant form of IBS (IBS-D) remains poorly understood, and current available therapeutic options for IBS-D are limited. Eluxadoline is a novel, locally acting mixed μ- and κ-opioid receptor agonist and δ-receptor antagonist approved by the Food and Drug Administration (FDA) for treatment of adults with IBS-D. Data from two phase III clinical trials showed that approximately 25–30% of the eluxadoline-treated patients achieved composite clinical response, defined by a reduction of abdominal pain and improvement in stool consistency. Patients who achieve composite response during the first month of therapy were significantly more likely to demonstrate sustained clinical response. The most common adverse events reported with eluxadoline use were constipation, nausea and abdominal pain. The risk of abuse, dependence, or withdrawal is low. Serious adverse events associated with eluxadoline include sphincter of Oddi spasm (SOS) and pancreatitis particularly in patients without a gallbladder. Development of pancreatitis is likely secondary to SOS, but it remains unclear why pancreatitis occurs so quickly after initial doses. This adverse event profile helps guide proper selection of IBS-D patients for eluxadoline use, with important contraindications including absence of a gallbladder, biliary duct obstruction or sphincter of Oddi dysfunction, alcoholism, history of pancreatitis, or structural diseases of the pancreas. With the recent clinical trials demonstrating its efficacy, eluxadoline provides an additional option to the few existing pharmacologic interventions available for IBS-D. In this review, we discuss the drug development, efficacy and safety of eluxadoline, as well as selection criteria for identifying appropriate candidates for this medication.
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Affiliation(s)
- Rebecca Liu
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kyle Staller
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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177
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Scarlata K, Catsos P, Smith J. From a Dietitian's Perspective, Diets for Irritable Bowel Syndrome Are Not One Size Fits All. Clin Gastroenterol Hepatol 2020; 18:543-545. [PMID: 31437487 DOI: 10.1016/j.cgh.2019.08.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/08/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Kate Scarlata
- Kate Scarlata Nutrition Consulting, Medway, Massachusetts.
| | | | - Janelle Smith
- University of California, Los Angeles, Los Angeles, California
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178
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Adding Chinese herbal medicine to probiotics for irritable bowel syndrome-diarrhea: A systematic review and meta-analysis of randomized controlled trials. JOURNAL OF TRADITIONAL CHINESE MEDICAL SCIENCES 2020. [DOI: 10.1016/j.jtcms.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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179
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Mullish BH, Quraishi MN, Segal JP, Ianiro G, Iqbal TH. The gut microbiome: what every gastroenterologist needs to know. Frontline Gastroenterol 2020; 12:118-127. [PMID: 33613943 PMCID: PMC7873547 DOI: 10.1136/flgastro-2019-101376] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 02/04/2023] Open
Abstract
The mucosal surfaces of the body are characterised by complex, specialised microbial communities, often referred to as the microbiome. However, only much more recently-with the development of technologies allowing exploration of the composition and functionality of these communities-has meaningful research in this area become feasible. Over the past few years, there has been rapid growth in interest in the gut microbiome in particular, and its potential contribution to gastrointestinal and liver disease. This interest has already extended beyond clinicians to pharmaceutical companies, medical regulators and other stakeholders, and is high profile among patients and the lay public in general. Such expansion of knowledge holds the intriguing potential for translation into novel diagnostics and therapeutics; however, being such a nascent field, there remain many uncertainties, unanswered questions and areas of debate.
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Affiliation(s)
- Benjamin H Mullish
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College of Science Technology and Medicine, London, UK
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohammed Nabil Quraishi
- University of Birmingham Microbiome Treatment Centre, University of Birmingham, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan P Segal
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gianluca Ianiro
- Digestive Disease Centre, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Gemelli, Rome, Italy
| | - Tariq H Iqbal
- University of Birmingham Microbiome Treatment Centre, University of Birmingham, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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180
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Chen FW, LeBrett WG, Yang L, Chang L. Opioid Prescription Patterns Among US Gastroenterologists From 2013 to 2017. Gastroenterology 2020; 158:776-779.e2. [PMID: 31647903 DOI: 10.1053/j.gastro.2019.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Frank W Chen
- Department of Medicine and Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Wendi G LeBrett
- Department of Medicine and Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Liu Yang
- Department of Medicine and Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Lin Chang
- Department of Medicine and Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
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181
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Shah ED, Almario CV, Spiegel BM, Chey WD. Presentation and Characteristics of Abdominal Pain Vary by Irritable Bowel Syndrome Subtype: Results of a Nationwide Population-Based Study. Am J Gastroenterol 2020; 115:294-301. [PMID: 31913193 PMCID: PMC7469977 DOI: 10.14309/ajg.0000000000000502] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Abdominal pain is a cardinal feature of irritable bowel syndrome (IBS); however, differences in abdominal pain among IBS subtypes remain unknown. We aimed to characterize abdominal pain symptoms among established IBS subtypes using data from the National Gastrointestinal (GI) Survey. METHODS Individuals participating in the National GI Survey completed National Institutes of Health GI Patient-Reported Outcomes Measurement Information System (GI-PROMIS) questionnaires. Adults meeting modified Rome III IBS criteria and reporting abdominal pain in the previous 7 days were eligible. Outcomes included abdominal pain severity, bothersomeness, interference with daily activities, frequency, and location. Results were stratified by subtype (diarrhea [IBS-D], constipation [IBS-C], and mixed [IBS-M]). Regression models adjusted for demographics and comorbidities. RESULTS One thousand one hundred fifty-eight individuals (245 IBS-D, 232 IBS-C, and 681 IBS-M) with active IBS symptoms (defined as abdominal pain in the past 7 days) were included. Demographics were similar among the subtypes except for age, race/ethnicity, education, and marital status. The GI-PROMIS score was lower for IBS-D (percentile score of 68.6, SD = 25.1; P = 0.001) and IBS-M (69.1, SD = 25.1; P < 0.001) compared with IBS-C (75.5, SD = 20.7). Abdominal pain was more bothersome (P = 0.001), caused more interference with daily activities (P = 0.03), and was more frequent (P = 0.047) for individuals with IBS-C compared with individuals with IBS-D. No differences in these domains were seen between individuals with IBS-D and IBS-M. Individuals with IBS-C and IBS-M had more widespread pain compared with those with IBS-D. DISCUSSION In this population-based study, we found that abdominal pain characteristics differ between the IBS subtypes. Namely, individuals with IBS-C experience more bothersome, frequent, and diffuse abdominal pain compared with those with IBS-D.
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Affiliation(s)
- Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher V. Almario
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brennan M. Spiegel
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
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182
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Black CJ, Yuan Y, Selinger CP, Camilleri M, Quigley EMM, Moayyedi P, Ford AC. Efficacy of soluble fibre, antispasmodic drugs, and gut–brain neuromodulators in irritable bowel syndrome: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2020; 5:117-131. [DOI: 10.1016/s2468-1253(19)30324-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/29/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022]
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183
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Zhu S, He M, Liu Z, Qin Z, Wang Z, Duan L. Shared genetic susceptibilities for irritable bowel syndrome and depressive disorder in Chinese patients uncovered by pooled whole-exome sequencing. J Adv Res 2020; 23:113-121. [PMID: 32099673 PMCID: PMC7029050 DOI: 10.1016/j.jare.2020.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/25/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023] Open
Abstract
Irritable bowel syndrome (IBS) is the most prevalent functional gastrointestinal disorder presenting a high comorbidity with depressive disorder (DD). Many studies have confirmed that these two disease share the similar pathophysiological process, but evidence of the genetic risks is limited. This study aimed to analyze the genetic susceptibilities for IBS and DD in Chinese patients. Pooled whole-exome sequencing (pooled-WES) was performed to identify the candidate variants in the group of diarrhea predominant IBS (IBS-D) patients, DD patients, and healthy controls (HC). Then, targeted sequencing was used to validate the candidate variants in three additional cohorts of IBS-D, DD, and HC. Four variants associated with both IBS-D and DD were identified through pooled-WES, and three of them were validated in targeted sequencing. SYT8 rs3741231 G allele and SSPO rs12536873 TT genotype were associated with both IBS-D and DD. The genes of these variants are important in neurogenesis and neurotransmission. In addition, we found COL6A1 rs13051496, a unique risk variation for IBS-D. It increased the IBS-D risk and had a positive correlation with the scores of abdominal bloating and dissatisfaction of bowel habits. Through the results of this study, it provides a genetic basis for the high comorbidity of IBS-D and DD.
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Affiliation(s)
- Shiwei Zhu
- Department of Gastroenterology, Peking University Third Hospital, No. 49 North Garden Rd., Haidian District, Beijing 100191, China
| | - Meibo He
- Department of Gastroenterology, Peking University Third Hospital, No. 49 North Garden Rd., Haidian District, Beijing 100191, China
| | - Zuojing Liu
- Department of Gastroenterology, Peking University Third Hospital, No. 49 North Garden Rd., Haidian District, Beijing 100191, China
| | - Zelian Qin
- Department of Plastic Surgery, Peking University Third Hospital, No.49 North Garden Rd., Haidian District, Beijing 100191, China
| | - Zhiren Wang
- Department of Science & Technology, Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Huilongguan Town, Changping District, Beijing 100096, China
| | - Liping Duan
- Department of Gastroenterology, Peking University Third Hospital, No. 49 North Garden Rd., Haidian District, Beijing 100191, China
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184
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Martoni CJ, Srivastava S, Leyer GJ. Lactobacillus acidophilus DDS-1 and Bifidobacterium lactis UABla-12 Improve Abdominal Pain Severity and Symptomology in Irritable Bowel Syndrome: Randomized Controlled Trial. Nutrients 2020; 12:E363. [PMID: 32019158 PMCID: PMC7071206 DOI: 10.3390/nu12020363] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022] Open
Abstract
This randomized, double-blind, placebo-controlled, multi-center study investigated the clinical efficacy of two probiotic strains on abdominal pain severity and symptomology in irritable bowel syndrome (IBS). Three hundred and thirty adults, aged 18 to 70 years, with IBS according to Rome IV criteria were allocated (1:1:1) to receive placebo, Lactobacillus acidophilus DDS-1 (1 × 1010 CFU/day) or Bifidobacterium animalis subsp. lactis UABla-12 (1 × 1010 CFU/day) over six weeks. The primary outcome was the change in Abdominal Pain Severity - Numeric Rating Scale (APS-NRS). Over the intervention period, APS-NRS was significantly improved in both probiotic groups vs. placebo in absolute terms (DDS-1: -2.59 ± 2.07, p = 0.001; UABla-12: -1.56 ± 1.83, p = 0.001) and in percentage of significant responders (DDS-1: 52.3%, p < 0.001); UABla-12 (28.2%, p = 0.031). Significant amelioration vs. placebo was observed in IBS Symptom Severity Scale (IBS-SSS) scores for L. acidophilus DDS-1 (-133.4 ± 95.19, p < 0.001) and B. lactis UABla-12 (-104.5 ± 96.08, p < 0.001) groups, including sub-scores related to abdominal pain, abdominal distension, bowel habits and quality of life. Additionally, a significant normalization was observed in stool consistency in both probiotic groups over time and as compared to placebo. In conclusion, L. acidophilus DDS-1 and B. lactis UABla-12 improved abdominal pain and symptom severity scores with a corresponding normalization of bowel habits in adults with IBS.
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Affiliation(s)
| | - Shalini Srivastava
- Vedic Lifesciences, 203 Morya Landmark1, New Link Road, Andheri W, Mumbai 400053, India;
| | - Gregory J. Leyer
- UAS Laboratories LLC, 4375 Duraform Lane, Windsor, WI 53598, USA;
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185
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Chey WD, Shah ED, DuPont HL. Mechanism of action and therapeutic benefit of rifaximin in patients with irritable bowel syndrome: a narrative review. Therap Adv Gastroenterol 2020; 13:1756284819897531. [PMID: 32047534 PMCID: PMC6984424 DOI: 10.1177/1756284819897531] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/02/2019] [Indexed: 02/04/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder with a multifactorial pathophysiology. The gut microbiota differs between patients with IBS and healthy individuals. After a bout of acute gastroenteritis, postinfection IBS may result in up to approximately 10% of those affected. Small intestinal bacterial overgrowth (SIBO) is more common in patients with IBS than in healthy individuals, and eradication of SIBO with systemic antibiotics has decreased symptoms of IBS in some patients with IBS and SIBO. The nonsystemic (i.e. low oral bioavailability) antibiotic rifaximin is indicated in the United States and Canada for the treatment of adults with IBS with diarrhea (IBS-D). The efficacy and safety of 2-week single and repeat courses of rifaximin have been demonstrated in randomized, placebo-controlled studies of adults with IBS. Rifaximin is widely thought to exert its beneficial clinical effects in IBS-D through manipulation of the gut microbiota. However, current studies indicate that rifaximin induces only modest effects on the gut microbiota of patients with IBS-D, suggesting that the efficacy of rifaximin may involve other mechanisms. Indeed, preclinical data reveal a potential role for rifaximin in the modulation of inflammatory cytokines and intestinal permeability, but these two findings have not yet been examined in the context of clinical studies. The mechanism of action of rifaximin in IBS is likely multifactorial, and further study is needed.
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Affiliation(s)
- William D. Chey
- Department of Nutrition Sciences, Division of Gastroenterology, Michigan Medicine, 3912 Taubman Center, SPC 5362, Ann Arbor, MI 48109-5362, USA
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Herbert L. DuPont
- Division of Epidemiology, Human Genetics and Environmental Sciences and Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA
- Mary W. Kelsey Chair in Medical Sciences, Division of Internal Medicine, University of Texas McGovern Medical School Houston, TX, USA
- Kelsey Research Foundation, Houston, TX, USA
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186
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Black CJ, Burr NE, Camilleri M, Earnest DL, Quigley EM, Moayyedi P, Houghton LA, Ford AC. Efficacy of pharmacological therapies in patients with IBS with diarrhoea or mixed stool pattern: systematic review and network meta-analysis. Gut 2020; 69:74-82. [PMID: 30996042 DOI: 10.1136/gutjnl-2018-318160] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/04/2019] [Accepted: 04/02/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Over half of patients with IBS have either diarrhoea (IBS-D) or a mixed stool pattern (IBS-M). The relative efficacy of licenced pharmacological therapies is unclear in the absence of head-to-head trials. We conducted a network meta-analysis to resolve this uncertainty. DESIGN We searched MEDLINE, Embase, Embase Classic, the Cochrane central register of controlled trials, and Clinicaltrials.gov through January 2019 to identify randomised controlled trials (RCTs) assessing the efficacy of licenced pharmacological therapies (alosetron, eluxadoline, ramosetron and rifaximin) in adults with IBS-D or IBS-M. Trials included in the analysis reported a dichotomous assessment of overall response to therapy, and data were pooled using a random effects model. Efficacy and safety of all pharmacological therapies were reported as a pooled relative risk with 95% CIs to summarise the effect of each comparison tested. Treatments were ranked according to their p score. RESULTS We identified 18 eligible RCTs (seven alosetron, five ramosetron, two rifaximin and four eluxadoline), containing 9844 patients. All were superior to placebo for the treatment of IBS-D or IBS-M at 12 weeks, according to the Food and Drug Administration (FDA)-recommended endpoint for trials in IBS. Alosetron 1 mg twice daily was ranked first for efficacy, based on the FDA-recommended composite endpoint of improvement in both abdominal pain and stool consistency, effect on global symptoms of IBS and effect on stool consistency. Ramosetron 2.5µg once daily was ranked first for effect on abdominal pain. Total numbers of adverse events were significantly greater with alosetron 1 mg twice daily and ramosetron 2.5µg once daily, compared with placebo. Rifaximin 550 mg three times daily ranked first for safety. Constipation was significantly more common with all drugs, except rifaximin 550 mg three times daily. CONCLUSION In a network meta-analysis of RCTs of pharmacological therapies for IBS-D and IBS-M, we found all drugs to be superior to placebo, but alosetron and ramosetron appeared to be the most effective.
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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, St. James's University Hospital, Leeds, UK
| | - Nicholas E Burr
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | | | - David L Earnest
- Division of Gastroenterology, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Eamonn Mm Quigley
- Division of Gastroenterology and Hepatology, The Methodist Hospital, Weill Cornell Medical College, Houston, Texas, USA
| | - Paul Moayyedi
- Department of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Lesley A Houghton
- Leeds Institute of Medical Research at St. James's, University of Leeds, 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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187
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Weerts ZZRM, Masclee AAM, Witteman BJM, Clemens CHM, Winkens B, Brouwers JRBJ, Frijlink HW, Muris JWM, De Wit NJ, Essers BAB, Tack J, Snijkers JTW, Bours AMH, de Ruiter-van der Ploeg AS, Jonkers DMAE, Keszthelyi D. Efficacy and Safety of Peppermint Oil in a Randomized, Double-Blind Trial of Patients With Irritable Bowel Syndrome. Gastroenterology 2020; 158:123-136. [PMID: 31470006 DOI: 10.1053/j.gastro.2019.08.026] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/05/2019] [Accepted: 08/14/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Peppermint oil is frequently used to treat irritable bowel syndrome (IBS), despite a lack of evidence for efficacy from high-quality controlled trials. We studied the efficacy and safety of small-intestinal-release peppermint oil in patients with IBS and explored the effects of targeted ileocolonic-release peppermint oil. METHODS We performed a double-blind trial of 190 patients with IBS (according to Rome IV criteria) at 4 hospitals in The Netherlands from August 2016 through March 2018; 189 patients were included in the intent-to-treat analysis (mean age, 34.0 years; 77.8% female; 57.7% in primary care), and 178 completed the study. Patients were randomly assigned to groups given 182 mg small-intestinal-release peppermint oil, 182 mg ileocolonic-release peppermint oil, or placebo for 8 weeks. The primary endpoint was abdominal pain response, as defined by the US Food and Drug Administration: at least a 30% decrease in the weekly average of worst daily abdominal pain compared with baseline in at least 4 weeks. The co-primary endpoint was overall relief of IBS symptoms, as defined by the European Medicines Agency. Secondary endpoints included abdominal pain, discomfort, symptom severity, and adverse events. RESULTS Abdominal pain response did not differ significantly between the peppermint oil and placebo groups: 29 of 62 patients in the small-intestinal-release peppermint oil group had a response (46.8%, P = .170 vs placebo), 26 of 63 patients in the ileocolonic-release peppermint oil group had a response (41.3%, P = .385 vs placebo), and 22 of 64 patients in the placebo group had a response (34.4%). We did not find differences among the groups in overall relief (9.7%, P = .317 and 1.6%, P = .351 vs 4.7% for placebo). The small intestinal peppermint oil did, however, produce greater improvements than placebo in secondary outcomes of abdominal pain (P = .016), discomfort (P = .020), and IBS severity (P = .020). Adverse events, although mild, were more common in both peppermint oil groups (P < .005). CONCLUSIONS In a randomized trial of patients with IBS, we found that neither small-intestinal-release nor ileocolonic-release peppermint oil (8 weeks) produced statistically significant reductions in abdominal pain response or overall symptom relief, when using US Food and Drug Administration/European Medicines Agency recommended endpoints. The small-intestinal-release peppermint oil did, however, significantly reduce abdominal pain, discomfort, and IBS severity. These findings do not support further development of ileocolonic-release peppermint oil for treatment of IBS. Clinicaltrials.gov, Number: NCT02716285.
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Affiliation(s)
- Zsa Zsa R M Weerts
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Ad A M Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ben J M Witteman
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands; Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Cees H M Clemens
- Department of Gastroenterology, Alrijne Zorggroep, Leiden, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, CAPHRI, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacobus R B J Brouwers
- Unit of Pharmacotherapy, Epidemiology, and Economics, University of Groningen, Groningen Research Institute of Pharmacy, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Groningen Research Institute of Pharmacy, The Netherlands
| | - Jean W M Muris
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Niek J De Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Brigitte A B Essers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Tack
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
| | - Johanna T W Snijkers
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Andrea M H Bours
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Daisy M A E Jonkers
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
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188
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Current US Food and Drug Administration-Approved Pharmacologic Therapies for the Treatment of Irritable Bowel Syndrome with Diarrhea. Adv Ther 2020; 37:83-96. [PMID: 31707713 DOI: 10.1007/s12325-019-01116-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by abdominal pain and alterations in stool form and/or frequency, leading to reduced quality of life. Pharmacologic agents currently approved by the US Food and Drug Administration for treatment of IBS with diarrhea (IBS-D) in adults are the nonsystemic antibiotic rifaximin, the mixed µ- and κ-opioid receptor agonist/δ-opioid antagonist eluxadoline, and the selective serotonin 5-HT3 antagonist alosetron (the last of which is indicated only in women with severe IBS-D refractory to conventional therapy). Both eluxadoline and alosetron are administered as chronic daily therapies; rifaximin is given as a 2-week course of treatment with repeat courses administered as needed for symptom recurrence. Presumed mechanisms of action of rifaximin include modulation of the gut microbiota, anti-inflammatory activity, normalization of visceral hypersensitivity, and reduction in intestinal permeability. Eluxadoline targets opioid receptors in the gastrointestinal (GI) tract, resulting in decreased GI motility, fluid secretion, and visceral pain perception. Alosetron antagonizes serotonergic afferent neural signals and also slows GI motility. The efficacy and safety of these agents have been investigated in several rigorous clinical trials, and it has been demonstrated that they improve global and individual IBS symptoms. This review highlights the pivotal efficacy and safety data of the three pharmacologic agents currently indicated in the USA for the management of IBS-D in adults.Funding: Salix Pharmaceuticals.
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189
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Rezaie A, Heimanson Z, McCallum R, Pimentel M. Lactulose Breath Testing as a Predictor of Response to Rifaximin in Patients With Irritable Bowel Syndrome With Diarrhea. Am J Gastroenterol 2019; 114:1886-1893. [PMID: 31688023 PMCID: PMC6903366 DOI: 10.14309/ajg.0000000000000444] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The nonsystemic antibiotic rifaximin is indicated for irritable bowel syndrome with diarrhea (IBS-D) in adults; however, determinants of response remain unclear. The utility of lactulose breath testing (LBT) in predicting response to rifaximin was examined. METHODS Adults with IBS-D received open-label rifaximin 550 mg 3 times daily for 2 weeks, followed by a 4-week posttreatment assessment period. Thirteen centers prospectively participated in this substudy. LBT was conducted before (day 1) and after (day 14) therapy (breath samples obtained every 15 minutes; up to 240 minutes). Patient response (decrease from baseline of ≥30% in abdominal pain and ≥50% decrease in frequency of mushy/watery stool), symptom improvement, and the relationship of clinical outcomes to LBT results were assessed. RESULTS A total of 93 patients were included; 62 (66.7%) had positive baseline LBT results. Overall, 48.4% (45/93) of patients responded to rifaximin; of these, 59.7% (37/62) had a positive baseline LBT vs 25.8% (8/31) with a negative LBT (P = 0.002; odds ratio 4.3, 95% confidence interval, 1.5-12.7). Patients with a positive baseline LBT result experienced significantly greater improvement from baseline in 6 of 7 individual IBS symptoms. LBT results after rifaximin therapy did not correlate with clinical response in the 86 patients with evaluable breath tests (P = 0.21); however, patients whose LBT results normalized after rifaximin had the highest response rate of 76.5% (13/17). DISCUSSION A positive baseline LBT result predicted a higher likelihood of response to rifaximin in IBS-D, suggesting a gut microbiome modulatory mechanism of action for rifaximin.
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Affiliation(s)
- Ali Rezaie
- GI Motility Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Richard McCallum
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Mark Pimentel
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
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190
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Shah ED, Saini SD, Chey WD. Value-based Pricing for Rifaximin Increases Access of Patients With Irritable Bowel Syndrome With Diarrhea to Therapy. Clin Gastroenterol Hepatol 2019; 17:2687-2695.e11. [PMID: 30831219 PMCID: PMC6717682 DOI: 10.1016/j.cgh.2019.02.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/08/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Increasing drug prices lead to payer coverage restrictions, which limit access to therapy. We assessed the cost effectiveness of rifaximin in management of patients with irritable bowel syndrome with diarrhea (IBS-D) under common payer coverage restrictions and determined the maximum price at which rifaximin would be cost effective using contemporary cost-effectiveness thresholds. METHODS A decision analytic model was constructed to evaluate quality of life, cost, and cost effectiveness of rifaximin for patients with IBS-D and complete noncoverage (insurer pays none of the drug cost), unrestricted access (insurer pays 100% of the drug cost), and formulary-restricted access (insurer pays 100% of the drug cost after for patients failed by initial therapy). The maximum cost-effective drug price was determined for each level of drug coverage using threshold analysis adjusted for willingness to pay thresholds from $50,000 to $150,000 per quality-adjusted life year (QALY). Analysis was performed from a payer perspective with a 1-year time horizon. RESULTS Unrestricted and formulary-restricted access were more effective than complete non-coverage, resulting in additional 0.03 and 0.05 QALYs gained over noncoverage. However, unrestricted and formulary-restricted coverage were more expensive. At current drug prices, unrestricted or formulary-restricted coverage would cost an additional $1,207,136 or $171,850/QALY gained, compared to complete non-coverage. A 12% to 62% price reduction ($18.46 to $26.34/pill) for formulary-restricted access and 84% to 88% price reduction ($3.53 to $4.71/pill) for unrestricted access would be needed for rifaximin to be a cost-effective treatment strategy. Rifaximin retreatment intervals, response rates, and adverse events were important factors in sensitivity analysis. CONCLUSION Using a decision analytic model, we show that payer coverage for rifaximin for patients with IBS-D exceeds generally accepted cost-effectiveness thresholds at current drug prices. Improved payer coverage could be justified using value-based pricing methods.
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Affiliation(s)
- Eric D. Shah
- Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH,Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI
| | - Sameer D. Saini
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI
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191
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The effects of inulin on gut microbial composition: a systematic review of evidence from human studies. Eur J Clin Microbiol Infect Dis 2019; 39:403-413. [DOI: 10.1007/s10096-019-03721-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/23/2019] [Indexed: 12/17/2022]
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192
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Hadjivasilis A, Tsioutis C, Michalinos A, Ntourakis D, Christodoulou DK, Agouridis AP. New insights into irritable bowel syndrome: from pathophysiology to treatment. Ann Gastroenterol 2019; 32:554-564. [PMID: 31700231 PMCID: PMC6826071 DOI: 10.20524/aog.2019.0428] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Irritable bowel syndrome (IBS) is the most common reason to visit a gastroenterologist. IBS was believed to be a functional disease, but many possible pathophysiologic mechanisms can now explain the symptoms. IBS patients are classified into subtypes according to their predominant bowel habit, based on the Rome IV criteria. These include diarrhea-predominant and constipation-predominant IBS, as well as the mixed type, a combination of the two. Usually, IBS treatment is based on the predominant symptoms, with many options for each subtype. A new promising treatment option, fecal microbiota transplantation, seems to have beneficial effects on IBS. However, treating the pathophysiological causative agent responsible for the symptoms is an emerging approach. Therefore, before the appropriate therapeutic option is chosen for treating IBS, a clinical evaluation of its pathophysiology should be performed.
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Affiliation(s)
- Alexandros Hadjivasilis
- School of Medicine, European University Cyprus, Nicosia, Cyprus (Alexandros Hadjivasilis, Constantinos Tsioutis, Adamantios Michalinos, Dimitrios Ntourakis, Aris P. Agouridis)
| | - Constantinos Tsioutis
- School of Medicine, European University Cyprus, Nicosia, Cyprus (Alexandros Hadjivasilis, Constantinos Tsioutis, Adamantios Michalinos, Dimitrios Ntourakis, Aris P. Agouridis)
| | - Adamantios Michalinos
- School of Medicine, European University Cyprus, Nicosia, Cyprus (Alexandros Hadjivasilis, Constantinos Tsioutis, Adamantios Michalinos, Dimitrios Ntourakis, Aris P. Agouridis)
| | - Dimitrios Ntourakis
- School of Medicine, European University Cyprus, Nicosia, Cyprus (Alexandros Hadjivasilis, Constantinos Tsioutis, Adamantios Michalinos, Dimitrios Ntourakis, Aris P. Agouridis)
| | - Dimitrios K Christodoulou
- Department of Gastroenterology, University Hospital of Ioannina, School of Health Sciences, University of Ioannina, Greece (Dimitrios K. Christodoulou)
| | - Aris P Agouridis
- School of Medicine, European University Cyprus, Nicosia, Cyprus (Alexandros Hadjivasilis, Constantinos Tsioutis, Adamantios Michalinos, Dimitrios Ntourakis, Aris P. Agouridis)
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193
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Cangemi DJ, Lacy BE. Management of irritable bowel syndrome with diarrhea: a review of nonpharmacological and pharmacological interventions. Therap Adv Gastroenterol 2019; 12:1756284819878950. [PMID: 31632456 PMCID: PMC6778998 DOI: 10.1177/1756284819878950] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/26/2019] [Indexed: 02/04/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) condition involving numerous potential causative factors (e.g. alterations in gut microbiota, motility, brain-gut axis). Several interventions are available for the management of patients with IBS, but no universal management algorithm currently exists. The aim of this article is to review interventions that may be considered in the management of patients with IBS with diarrhea (IBS-D). Nonpharmacological interventions include dietary and lifestyle modification, which are generally used as first-line therapy. Probiotics have demonstrated efficacy and safety in patients with IBS, but studies are inconsistent in strains examined, dosing, and treatment duration. Psychological therapies (e.g. cognitive behavioral therapy, hypnotherapy) also may improve IBS symptoms. Pharmacological interventions for the management of IBS-D include the US Food and Drug Administration-approved agents eluxadoline, rifaximin, and alosetron, as well as loperamide, smooth muscle antispasmodics, bile acid sequestrants, and antidepressants (i.e. tricyclic antidepressants, selective serotonin reuptake inhibitors). Eluxadoline and rifaximin have been shown to improve abdominal pain and stool consistency in patients with IBS-D. In addition, data indicate that alosetron improves IBS symptoms; however, it is approved only for women with severe IBS-D. Of the three approved agents, rifaximin has the most favorable safety profile. The risk-benefit ratio is an important consideration with every medication, but is especially important in the treatment of functional GI disorders such as IBS-D. Thus, the most troublesome symptoms, quality of life, symptom intensity, and individual patient preferences should be considered when formulating a management plan for patients with IBS-D.
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Affiliation(s)
- David J. Cangemi
- Division of Gastroenterology and Hepatology, Section of Gastroenterology, Mayo Clinic, Jacksonville, FL, USA
| | - Brian E. Lacy
- Division of Gastroenterology and Hepatology, Section of Gastroenterology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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194
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Ford AC, Gibson PR. Efficacy of glutamine in postinfection IBS. Gut 2019; 68:1905-1906. [PMID: 30244201 DOI: 10.1136/gutjnl-2018-317438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/05/2018] [Accepted: 09/08/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Alexander Charles Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
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195
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Efficacy and Safety of Eluxadoline in Patients With Irritable Bowel Syndrome With Diarrhea Who Report Inadequate Symptom Control With Loperamide: RELIEF Phase 4 Study. Am J Gastroenterol 2019; 114:1502-1511. [PMID: 31356229 PMCID: PMC6738625 DOI: 10.14309/ajg.0000000000000327] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Irritable bowel syndrome with diarrhea (IBS-D) is a functional gastrointestinal disorder with limited effective treatment options. We evaluated the efficacy and safety of eluxadoline in patients with IBS-D who reported inadequate symptom control with prior loperamide. METHODS Three hundred forty-six adults with IBS-D (Rome III criteria) were randomly assigned to placebo or eluxadoline 100 mg twice daily for 12 weeks. Patients recorded daily IBS-D symptoms, including worst abdominal pain (WAP) and stool consistency (through Bristol Stool Scale). The primary endpoint was proportion of composite responders, defined as patients who met daily composite response criteria (≥40% WAP improvement and <5 Bristol Stool Scale score) for at least 50% of treatment days, and recorded ≥60 days of diary entries over the 12-week period. RESULTS Over 12 weeks, a significantly greater proportion of eluxadoline patients achieved the primary composite responder endpoint compared to placebo (22.7% vs 10.3%, P = 0.002), and component endpoints of improvements in stool consistency (27.9% vs 16.7%, P = 0.01) and WAP (43.6% vs 31.0%, P = 0.02). Additionally, a greater proportion of eluxadoline patients met the composite responder endpoint assessed at monthly intervals compared to placebo (weeks 1-4: 14.0% vs 6.9%, P = 0.03; weeks 5-8: 26.7% vs 14.9%, P = 0.006; weeks 9-12: 30.8% vs 16.7%, P = 0.002). Rates of adverse events were comparable in both groups (37.4% vs 35.3%); no treatment-related serious adverse event, cases of sphincter of Oddi spasm, or pancreatitis were reported. DISCUSSION Eluxadoline appears safe and effective for treating IBS-D symptoms in patients with an intact gallbladder reporting inadequate relief with prior loperamide use.
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196
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Wang L, Alammar N, Singh R, Nanavati J, Song Y, Chaudhary R, Mullin GE. Gut Microbial Dysbiosis in the Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Case-Control Studies. J Acad Nutr Diet 2019; 120:565-586. [PMID: 31473156 DOI: 10.1016/j.jand.2019.05.015] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 05/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is the most common functional digestive condition in the industrialized world. The gut microbiota plays a key role in disease pathogenesis. OBJECTIVE A systematic review and meta-analysis on case-control studies was conducted to determine whether there is gut microbial dysbiosis in participants with IBS in comparison with healthy controls and, if so, whether the dysbiosis pattern differs among IBS subtypes and geographic regions. METHODS This review was conducted and reported according to the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) 2000 and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 guidelines. Research articles published up to May 9, 2018 were identified through MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (Cochrane Library), ClinicalTrials.gov, EMBASE, and Web of Science. Study quality was assessed using the Newcastle-Ottawa Scale. Case-control studies of participants with IBS who had undergone quantitative gut microbial stool analysis were included. The primary exposure measure of interest is log10 bacterial counts per gram of stool. Meta-analyses were performed to estimate the mean difference (MD) in gut microbiota between participants with IBS and healthy controls using the random-effects model with inverse variance in Revman 5.3 and R 3.5.1. Publication bias was assessed with funnel plots and Egger's test. Between-study heterogeneity was analyzed using Higgins I2 statistic with 95% CIs. RESULTS There were 6,333 unique articles identified; 52 qualified for full-text screening. Of these, 23 studies were included for analysis (n=1,340 participants from North America, Europe, and Asia). Overall, the studies were moderate in quality. Comparing participants with IBS to healthy controls, lower fecal Lactobacillus (MD= -0.57 log10 colony-forming unit [CFU]/g; P<0.01) and Bifidobacterium (MD= -1.04 log10CFU/g; P<0.01), higher Escherichia coli (MD=0.60 log10CFU/g; P<0.01), and marginally higher Enterobacter (MD=0.74 log10CFU/g; P=0.05). No difference was found between participants with IBS and healthy controls in fecal Bacteroides and Enterococcus (P=0.18 and 0.68, respectively). Publication bias was not observed except in Bifidobacterium (P=0.015). Subgroup analyses on participants with diarrhea-predominant and constipation-predominant IBS showed consistent results with the primary results. A subgroup analysis of Chinese studies was consistent with the primary results, except for fecal Bacteroides, which was increased in participants with IBS vs healthy controls (MD=0.29; 95% CI 0.13 to 0.46; P<0.01). Although substantial heterogeneity was detected (I2>75%) in most comparisons, the direction of the effect estimates is relatively consistent across studies. CONCLUSIONS IBS is characterized by gut microbial dysbiosis. Prospective, large-scale studies are needed to delineate how gut microbial profiles can be used to guide targeted therapies in this challenging patient population.
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197
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Barros LL, Farias AQ, Rezaie A. Gastrointestinal motility and absorptive disorders in patients with inflammatory bowel diseases: Prevalence, diagnosis and treatment. World J Gastroenterol 2019; 25:4414-4426. [PMID: 31496621 PMCID: PMC6710178 DOI: 10.3748/wjg.v25.i31.4414] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/04/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), Crohn`s disease and ulcerative colitis, are chronic conditions associated with high morbidity and healthcare costs. The natural history of IBD is variable and marked by alternating periods of flare and remission. Even though the use of newer therapeutic targets has been associated with higher rates of mucosal healing, a great proportion of IBD patients remain symptomatic despite effective control of inflammation. These symptoms may include but not limited to abdominal pain, dyspepsia, diarrhea, urgency, fecal incontinence, constipation or bloating. In this setting, commonly there is an overlap with gastrointestinal (GI) motility and absorptive disorders. Early recognition of these conditions greatly improves patient care and may decrease the risk of mistreatment. Therefore, in this review we describe the prevalence, diagnosis and treatment of GI motility and absorptive disorders that commonly affect patients with IBD.
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Affiliation(s)
- Luísa Leite Barros
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
| | - Alberto Queiroz Farias
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
| | - Ali Rezaie
- Division of Gastroenterology, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA 90048, United States
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198
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Recent Advances in Cognitive Behavioral Therapy For Digestive Disorders and the Role of Applied Positive Psychology Across the Spectrum of GI Care. J Clin Gastroenterol 2019; 53:477-485. [PMID: 31169757 DOI: 10.1097/mcg.0000000000001234] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although cognitive behavior therapies (CBTs) have shown great promise in the reduction of symptom burden from as well as anxiety around various gastrointestinal (GI) disorders, there are substantial issues involving the scalable delivery of such interventions within the clinical setting of a gastroenterology practice, leaving most patients without access to psychological care. GOALS This paper discusses the application of positive psychology principles and techniques for adoption by various GI providers to initiate early, effective psychological care for patients with GI disorders, saving CBTs for more complex cases. STUDY/RESULTS Authors provide a comprehensive framework of patient well-being known as REVAMP, which is consistent with CBT principles, and elaborate on research and interventions that can be adopted within the gastroenterology practice setting. Building positive resources can bolster patients with GI disorders against comorbid psychological and psychiatric distress. CONCLUSIONS Positive psychology interventions can be implemented within gastroenterology practice. Research is necessary to evaluate the efficacy and acceptability of positive psychology interventions among patients with different digestive disorders and baseline psychological characteristics, as well as the feasibility of administration by different clinicians in the gastroenterology practice setting.
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199
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Is Bacillus coagulans supplementation plus low FODMAP diet superior to low FODMAP diet in irritable bowel syndrome management? Eur J Nutr 2019; 59:2111-2117. [PMID: 31327047 DOI: 10.1007/s00394-019-02060-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to assess the superiority of low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet plus Bacillus coagulans supplementation to low FODMAP diet alone in the reduction of irritable bowel syndrome (IBS) symptoms. METHODS In this randomized clinical trial, fifty IBS patients who met Rome IV criteria for IBS were randomly assigned to receive a low FODMAP diet plus either a probiotic or a placebo capsule for 8 weeks. Probiotic capsules contained 109B. coagulans spores and 400 mg inulin, while placebo capsules consisted of 500 mg rice starch. RESULTS Significant improvements were observed in abdominal pain intensity and frequency, abdominal distension, satisfaction with bowel habits, quality of life, defecation consistency, and patient-reported severity score in both groups; however, only improvement in severity score was significantly higher in probiotic group compared with placebo group (P = 0.001). Moreover, the frequency of patients with clinical improvement in IBS-symptom severity scale (IBS-SSS) was significantly more in probiotic group compared to placebo group (P = 0.038). CONCLUSION Our results indicate that the addition of probiotic supplement containing B. coagulans to the low FODMAP diet might be superior to low FODMAP diet in alleviating IBS symptoms.
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200
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Moayyedi P. Faecal microbiota transplantation for IBS: still a long way to go. Lancet Gastroenterol Hepatol 2019; 4:656-657. [PMID: 31326346 DOI: 10.1016/s2468-1253(19)30226-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/04/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada.
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