Common functional gastrointestinal disorders: nonulcer dyspepsia and irritable bowel syndrome

Prescript-assist probiotic-prebiotic treatment for irritable bowel syndrome: an open-label, partially controlled, 1-year extension of a previously published controlled clinical trial

OBJECTIVE

The aim of this study was to extend a previous 2-week assessment of a probiotic-prebiotic complex in patients with irritable bowel syndrome (IBS).

METHODS

In this open-label, partially controlled, 1-year (14 [2] months) extension study, data were collected from patients with IBS who continued treatment following a 2-week study of the efficacy of the probiotic-prebiotic complex. Data were collected at 2 and approximately 60 weeks after the end of the original study.

RESULTS

A total of 25 patients entered the 2-week extension and 22 completed the approximately 60-week follow-up study (20 women, 2 men; age range, 20-70 years; all white). Results in the control group 2 weeks after crossover to treatment were similar to those from the original study, with reductions in IBS subsyndromes, as follows: general ill feelings/nausea (P < 0.001), indigestion/flatulence (P < 0.001), and marginally colitis (P < 0.03 [1-tailed]). Treatment was associated with a continued reduction in general ill feelings/nausea at 4 weeks (P < 0.007). At >or=52-week follow-up, the rate of remissions was 81.5% to 100% (P < 0.003).

CONCLUSION

Based on the results from the present 1-year extension study, treatment with this probiotic-prebiotic complex may be an option for short-term (2-4 weeks) and long-term ( approximately 60-week) reductions in IBS symptoms.

Prescript-Assist probiotic-prebiotic treatment for irritable bowel syndrome: a methodologically oriented, 2-week, randomized, placebo-controlled, double-blind clinical study

BACKGROUND

The symptomatic efficacy of Prescript-Assist (Safer Medical, Inc., Fort Benton, Montana), a treatment combining probiotic and prebiotic components, has previously been evaluated clinically only in an open-label study in patients with various gastrointestinal conditions, including irritable bowel syndrome (IBS).

OBJECTIVES

This study was conducted primarily to compare the effects of Prescript-Assist with placebo in patients with a diagnosis of IBS. Toward this objective, a secondary methodologic goal was to determine the number and nature of symptom clusters ("subsyndromic factors") that characterize IBS.

METHODS

This was a double-blind, placebo-controlled clinical study in which patients were randomly assigned to receive either Prescript-Assist one 500-mg capsule BID or 1 placebo capsule BID for 2 weeks. Thirteen IBS symptoms identified from the clinical literature were embedded in a larger research instrument. Using a scale from 0 to 5, patients rated the intensity of these symptoms for the 7-day period immediately before the start of treatment, at the end of each study week, and after each of the 2 subsequent weeks (during which all patients received open-label Prescript-Assist as part of a larger study evaluating methodologic approaches to enhancing assessments of medication efficacy/safety). The symptom-intensity data were subjected to maximum likelihood factor analysis with varimax rotation to identify any IBS subsyndromic factors, and the effect of treatment on each of the identified factors was evaluated using analyses of covariance with appropriate baseline-week assessments as covariate controls.

RESULTS

The study included 25 patients with IBS (23 women, 2 men; age range, 20-70 years). Three subsyndromic factors were identified that together accounted for 60.2% of total IBS symptom variance: factor 1, general ill feelings/nausea; factor 2, indigestion/flatulence; and factor 3, colitis. Treatment with Prescript-Assist was associated with significant reductions in each of the subsyndromic factors. Factor 1 was significantly reduced by 0.345 standard score units (F(1,46) = 4.26; P = 0.042), factor 2 by 0.544 standard score units (F(1,46) = 7.83; P = 0.008), and factor 3 by 0.826 standard score units (F(1,46) = 10.20; P = 0.003).

CONCLUSIONS

This study identified 3 subsyndromic factors of IBS: general ill feelings/nausea, indigestion/flatulence, and colitis. In this methodologically oriented double-blind study in patients with IBS, combined probiotic-prebiotic treatment with Prescript-Assist was associated with significant reductions in these factors.

Tegaserod is effective in the initial and retreatment of irritable bowel syndrome with constipation

BACKGROUND

Symptoms of irritable bowel syndrome are often cyclical and thus may require repeated rather than continuous therapy. Tegaserod is effective and well-tolerated for irritable bowel syndrome with constipation but data on retreatment are lacking.

AIM

To assess whether tegaserod retreatment is as efficacious and well-tolerated as initial treatment in a primary care setting.

METHODS

This open-label trial was designed to evaluate the effectiveness of tegaserod under real-life conditions. Irritable bowel syndrome with constipation patients received tegaserod 6 mg b.d. for 12 weeks; response was assessed at weeks 4 and 12. Responders (those achieving satisfactory relief for at least 2 of the previous 4 weeks) at weeks 4 and/or 12 entered an 8-week withdrawal period where symptom recurrence was assessed. Patients experiencing recurrence could receive tegaserod 6 mg b.d. for another 4 weeks (retreatment phase) and on completion, could choose to continue tegaserod in a 6-month extension study.

RESULTS

A total of 513 patients received initial treatment with tegaserod; 85.0% (436 of 513) responded. 403 responders entered the withdrawal period; symptoms recurred in 83.9% (338 of 403) after a mean of 38 days. Of the 307 patients who subsequently entered retreatment 89.3% (274 of 307) responded. Among patients entering the retreatment period, 269 (87.6%) had responded within the first 4 weeks of initial treatment. Of these, 243 (90.3%) responded to tegaserod retreatment. Adverse events were infrequent and similar during 4 weeks of the initial treatment period (11.1%) and on retreatment (10.4%). The extension study, completed by 188 of 232 (81.0%) patients, demonstrated good long-term tolerability of tegaserod.

CONCLUSIONS

Irritable bowel syndrome with constipation patients can be successfully treated, and retreated, with tegaserod 6 mg b.d. Tegaserod was well-tolerated during initial and retreatment periods.

The effects of withdrawing tegaserod treatment in comparison with continuous treatment in irritable bowel syndrome patients with abdominal pain/discomfort, bloating and constipation: a clinical study

BACKGROUND

The post-withdrawal characteristics of tegaserod treatment in patients with irritable bowel syndrome with constipation remain undefined.

AIM

To evaluate the effects of continuous tegaserod treatment, versus intermittent or withdrawal of treatment in patients with irritable bowel syndrome with constipation.

METHODS

In a randomized, open-label trial, all patients initially received tegaserod 6 mg b.d. Responders were randomized to continue or withdraw from treatment for 8 weeks and symptom recurrence was assessed. Tegaserod was re-introduced in withdrawal patients who experienced symptom recurrence, allowing an assessment of intermittent treatment. Two separate analyses assessed the effects of intermittent and withdrawal of treatment on symptom recurrence.

RESULTS

Five hundred irritable bowel syndrome with constipation patients initially received tegaserod; 410 completed treatment. Time to symptom recurrence was shorter in withdrawal patients than those maintained on tegaserod. Significantly more patients maintained on tegaserod had not experienced symptom recurrence by week 8, compared with intermittent (86.5% vs. 58.1%, respectively) or withdrawal of treatment (69.2% vs. 11.3%, respectively) (P < 0.0001 for both). Significant treatment effects were observed for bloating (P < 0.01) and abdominal pain/discomfort (P < 0.02). Most adverse events were mild to moderate.

CONCLUSIONS

Irritable bowel syndrome with constipation patients who receive continuous or intermittent tegaserod are less likely to experience symptom recurrence than patients withdrawn from treatment.

Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life

OBJECTIVE

To test the hypothesis that noxious stimulation at birth may increase the long-term risk for developing psychosomatic or functional disorders during later life.

STUDY DESIGN

Matched case-control study using sibling controls. The birth records were retrieved for the offspring of 494 mothers who, after uncomplicated pregnancies, had delivered two or more children with birth weights at least 2500 g, if at least one child was exposed to a perinatal complication or birth asphyxia. Among their offspring (N=1110), the 108 cases hospitalized for functional intestinal symptoms were identified from nationwide hospital discharge records. Of these, 96 cases were compared with 116 unaffected sibling controls.

RESULTS

Functional intestinal symptoms occurred more commonly among the 1110 subjects (9.5%) than in the general population (3.4%, chi(2)=124, P<10(-6)). Gastric suction at birth occurred more frequently among the cases compared with their siblings (22.9% vs 11.2%). There were no differences in the number of cases and controls exposed to perinatal trauma or birth asphyxia. Multivariate logistic regression analyses showed that gastric suction at birth was associated with functional intestinal disorders during later life (odds ratio, 2.99; 95% confidence interval, 1.32-6.79; P=.009), whereas maternal, perinatal, or other confounding variables were not significant.

CONCLUSIONS

Noxious stimulation caused by gastric suction at birth may promote the development of long-term visceral hypersensitivity and cognitive hypervigilance, leading to an increased prevalence of functional intestinal disorders in later life.

Long-term safety of tegaserod in patients with constipation-predominant irritable bowel syndrome

BACKGROUND

Tegaserod is a 5-hydroxytryptamine-4 receptor partial agonist. Oral administration causes gastrointestinal effects resulting in increased gastrointestinal motility and attenuation of visceral sensation.

AIM

: To determine the long-term safety and tolerability of tegaserod in patients suffering from irritable bowel syndrome with constipation as the predominant symptom of altered bowel habits.

METHOD

A multicentre, open-label study with flexible dose titration of tegaserod in out-patients suffering from constipation-predominant irritable bowel syndrome.

RESULTS

A total of 579 patients with constipation-predominant irritable bowel syndrome were treated with tegaserod. Of these, 304 (53%) completed the trial. The most common adverse events, classified as related to tegaserod for any dose, were mild and transient diarrhoea (10.1%), headache (8.3%), abdominal pain (7.4%) and flatulence (5.5%). Forty serious adverse events were reported in 25 patients (4.4% of patients) leading to discontinuation in six patients. There was one serious adverse event, acute abdominal pain, classified as possibly related to tegaserod. There were no consistent differences in adverse events between patients previously exposed to tegaserod and those treated de novo. No pattern-forming tegaserod-related abnormalities in haematological and biochemical laboratory tests, urinalysis, blood pressure, pulse rate or electrocardiograms were found.

CONCLUSIONS

Tegaserod appears to be well tolerated in the treatment of patients with constipation-predominant irritable bowel syndrome. The adverse event profile, clinical laboratory evaluations, vital signs and electrocardiogram recordings revealed no evidence of any unexpected adverse events, and suggest that treatment is safe over a 12-month period.

Diagnostic approach to the patient with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder characterized by abdominal pain or discomfort and alterations in bowel habits. In clinical practice, diagnosis is based on positive symptoms known as the Rome criteria and limited diagnostic screen, taking into account warning features suggestive of organic disease. Minimal diagnostic tests are warranted to rule out structural lesions in a cost-effective manner and to convince the patient of the diagnosis of IBS. An initial diagnosis of IBS is safe and rarely needs revision over time. Persistence of symptoms is to be expected and does not justify suspicion of other diagnoses. Only change in the clinical pattern over time justifies additional investigations. Other diagnostic evaluations depend on predominant symptoms, namely constipation, diarrhea, and pain or discomfort. It should be emphasized that although an initial "positive diagnosis" is safe to exclude other diseases with similar symptoms, a common disorder such as IBS may often coexist with other asymptomatic disorders.