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Di Ciaula A, Khalil M, Baffy G, Portincasa P. Advances in the pathophysiology, diagnosis and management of chronic diarrhoea from bile acid malabsorption: a systematic review. Eur J Intern Med 2024:S0953-6205(24)00291-7. [PMID: 39069430 DOI: 10.1016/j.ejim.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/30/2024]
Abstract
Bile acid malabsorption (BAM) is an important disorder of digestive pathophysiology as it generates chronic diarrhoea. This condition originates from intricate pathways involving bile acid synthesis and metabolism in the liver and gut, the composition of gut microbiota, enterohepatic circulation and key receptors as farnesoid X receptor (FXR), fibroblast growth factor receptor 4 (FGFR4), and the G-protein bile acid receptor-1 (GPBAR-1). Although symptoms can resemble those related to disorders of gut brain interaction, accurate diagnosis of BAM may greatly benefit the patient. The empiric diagnosis of BAM is primarily based on the clinical response to bile acid sequestrants. Specific tests including the 48-hour fecal bile acid test, serum levels of 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor 19 (FGF19), and the 75Selenium HomotauroCholic Acid Test (SeHCAT) are not widely available. Nevertheless, lack of diagnostic standardization of BAM may account for poor recognition and delayed management. Beyond bile acid sequestrants, therapeutic approaches include the use of FXR agonists, FGF19 analogues, glucagon-like peptide-1 (GLP-1) receptor agonists, and microbiota modulation. These novel agents can best make their foray into the therapeutic armamentarium if BAM does not remain a diagnosis of exclusion. Ignoring BAM as a specific condition may continue to contribute to increased healthcare costs and reduced quality of life. Here, we aim to provide a comprehensive review of the pathophysiology, diagnosis, and management of BAM.
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Affiliation(s)
- Agostino Di Ciaula
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari "Aldo Moro", Medical School, Bari, Italy.
| | - Mohamad Khalil
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari "Aldo Moro", Medical School, Bari, Italy.
| | - Gyorgy Baffy
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Section of Gastroenterology, Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari "Aldo Moro", Medical School, Bari, Italy.
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2
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Ellegaard AM, Kårhus ML, Knop FK. Comment on Yang et al. Bile Acid Diarrhea: From Molecular Mechanisms to Clinical Diagnosis and Treatment in the Era of Precision Medicine. Int. J. Mol. Sci. 2024, 25, 1544. Int J Mol Sci 2024; 25:8047. [PMID: 39125615 PMCID: PMC11311566 DOI: 10.3390/ijms25158047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/15/2024] [Indexed: 08/12/2024] Open
Abstract
We have with great interest read the recent review on the molecular mechanisms underlying bile acid diarrhea (BAD) by Yang et al [...].
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Affiliation(s)
- Anne-Marie Ellegaard
- Center for Clinical Metabolic Research, Copenhagen University Hospital—Herlev and Gentofte, DK-2900 Hellerup, Denmark
| | - Martin L. Kårhus
- Center for Clinical Metabolic Research, Copenhagen University Hospital—Herlev and Gentofte, DK-2900 Hellerup, Denmark
| | - Filip K. Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital—Herlev and Gentofte, DK-2900 Hellerup, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, The Faculty of Health and Medical Sciences, Copenhagen University, DK-2200 Copenhagen, Denmark
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3
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Herfarth H, Long MD, Hansen JJ, Anderson C, English E, Buse JB, Barnes EL. Efficacy and Safety of Liraglutide in Patients With an Ileal Pouch-Anal Anastomosis and Chronic High Bowel Frequency: A Placebo-Controlled, Crossover, Proof-of-Concept Study. Am J Gastroenterol 2024; 119:00000434-990000000-01116. [PMID: 38668926 PMCID: PMC11365596 DOI: 10.14309/ajg.0000000000002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/04/2024] [Indexed: 05/23/2024]
Abstract
INTRODUCTION After colectomy with ileoanal pouch anastomosis (IPAA), many patients develop high bowel frequency (BF) refractory to antimotility agents, despite normal IPAA morphology. Low circulating levels of glucagon-like protein-1 (GLP-1), a modulator of gastroduodenal motility, have been reported after colectomy. METHODS Double-blind crossover study of 8 IPAA patients with refractory high BF treated with daily administration of the GLP-1 receptor agonist liraglutide or placebo. RESULTS Liraglutide, but not placebo, reduced daily BF by more than 35% ( P < 0.03). DISCUSSION Larger randomized controlled studies are warranted to delineate the treatment potential of GLP-1 receptor agonists in IPAA patients suffering from noninflammatory high BF.
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Affiliation(s)
- Hans Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Millie D. Long
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jonathan J. Hansen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Chelsea Anderson
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Emily English
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John B. Buse
- Division of Endocrinology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Jansson-Rehnberg AS, Drewes AM, Sponheim J, Borgfelt C, Münch A, Graf W, Simrén M, Lindberg G, Hellström PM. Diarrhoea of unknown cause: medical treatment in a stepwise manner Management of Idiopathic Diarrhoea Based on Experience of Step-Up Medical Treatment. Scand J Gastroenterol 2024; 59:543-546. [PMID: 38343268 DOI: 10.1080/00365521.2024.2313061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/25/2024] [Indexed: 04/26/2024]
Abstract
The basic principle for the treatment of idiopathic diarrhoea (functional diarrhoea K59.1) is to delay transit through the gut in order to promote the absorption of electrolytes and water. Under mild conditions, bulking agents may suffice. With increasing severity, antidiarrhoeal pharmaceuticals may be added in a stepwise manner. In diarrhoea of unknown aetiology, peripherally-acting opioid receptor agonists, such as loperamide, are first-line treatment and forms the pharmaceutical basis of antidiarrheal treatment. As second-line treatment opium drops have an approved indication for severe diarrhoea when other treatment options fail. Beyond this, various treatment options are built on experience with more advanced treatments using clonidine, octreotide, as well as GLP-1 and GLP-2 analogs which require specialist knowledge the field.
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Affiliation(s)
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jon Sponheim
- Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Christer Borgfelt
- Department of obstetrics and gynaecology, Skåne University Hospital, Lund, Sweden
| | - Andreas Münch
- Department of Gastrointestinal Medicine, University Hospital, Linköping, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, University of Uppsala, Sweden
| | - Magnus Simrén
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Greger Lindberg
- Department of Medicine, Karolinska University Hospital, Huddinge, Sweden
| | - Per M Hellström
- Department of Medical Sciences, University of Uppsala, Sweden
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5
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Kårhus ML, Ellegaard AM, Knop FK, Kårhus LL. The Epidemiology of Bile Acid Diarrhea in Denmark [Response to Letter]. Clin Epidemiol 2024; 16:7-8. [PMID: 38250453 PMCID: PMC10799645 DOI: 10.2147/clep.s455102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Affiliation(s)
- Martin L Kårhus
- Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark
| | - Anne-Marie Ellegaard
- Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Line L Kårhus
- Center for Clinical Research and Prevention, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Frederiksberg, Denmark
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6
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Kårhus ML, Ellegaard AM, Winther-Jensen M, Hansen S, Knop FK, Kårhus LL. The Epidemiology of Bile Acid Diarrhea in Denmark. Clin Epidemiol 2023; 15:1173-1181. [PMID: 38089008 PMCID: PMC10712339 DOI: 10.2147/clep.s442054] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVE Bile acid diarrhea (BAD) is a socially debilitating disease with frequent bowel movements, urgency, and fecal incontinence as the main symptoms. It is caused by excessive bile acid levels in the colon and is most commonly treated with bile acid sequestrants. It is estimated that 1-2% of the population suffers from the disease, but only a fraction of these are properly diagnosed with the gold standard ⁷⁵selenium-homotaurocholic acid (SeHCAT) test. Here, we use nationwide registries to describe the demographic characteristics of individuals suffering from BAD in Denmark. METHODS Since the International Classification of Diseases diagnosis code for BAD was not used until 2021, we identified the BAD population by referral to SeHCAT testing followed by a prescription of a bile acid sequestrant (colestyramine, colestipol or colesevelam) within 365 days. The study period was from 2003 to 2021. RESULTS During the study period, a total of 5264 individuals with BAD were identified with large differences between the five regions in Denmark. The number of prescriptions of colestyramine and colesevelam, the number of SeHCAT tests, and the number of individuals diagnosed with BAD increased during the study period. The BAD population had more co-morbidities and more health care contacts as well as lower levels of education and income compared with age- and sex-matched controls from the general population. CONCLUSION Using the Danish registries, we identified a BAD population, which seems to be inferior in health care and socio-economic parameters compared with the Danish general population.
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Affiliation(s)
- Martin L Kårhus
- Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark
| | - Anne-Marie Ellegaard
- Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark
| | - Matilde Winther-Jensen
- Center for Clinical Research and Prevention, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| | - Susanne Hansen
- Center for Clinical Research and Prevention, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Line L Kårhus
- Center for Clinical Research and Prevention, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Frederiksberg, Denmark
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7
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Huang RL, Huang WK, Xiao XY, Ma LF, Gu HZR, Yang GP. Diagnosis and treatment of post-cholecystectomy diarrhoea. World J Gastrointest Surg 2023; 15:2398-2405. [PMID: 38111762 PMCID: PMC10725554 DOI: 10.4240/wjgs.v15.i11.2398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/22/2023] [Accepted: 09/22/2023] [Indexed: 11/26/2023] Open
Abstract
The incidence of cholecystitis is relatively high in developed countries and may usually be attributed to gallstones, the treatment for which involves complete surgical removal of the gallbladder (cholecystectomy). Bile acids produced following cholecystectomy continue to flow into the duodenum but are poorly absorbed by the colon. Excessive bile acids in the colon stimulate mucosal secretion of water and electrolytes leading, in severe cases, to diarrhoea. Bile acid diarrhoea (BAD) is difficult to diagnose, requiring a comprehensive medical history and physical examination in combination with laboratory evaluation. The current work reviews the diagnosis and treatment of BAD following cholecystectomy.
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Affiliation(s)
- Rang-Lang Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Third Xiangya Hospital of The Central South University, Changsha 410013, Hunan Province, China
| | - Wen-Kai Huang
- Department of General Medicine, The Third Xiangya Hospital of The Central South University, Changsha 410013, Hunan Province, China
| | - Xiang-Yi Xiao
- The Xiangya School of Medicine, The Central South University, Changsha 410013, Hunan Province, China
| | - Lin-Feng Ma
- The Xiangya School of Medicine, The Central South University, Changsha 410013, Hunan Province, China
| | - He-Zi-Rui Gu
- The Xiangya School of Medicine, The Central South University, Changsha 410013, Hunan Province, China
| | - Guo-Ping Yang
- Department of Clinical Pharmacy, The Third Hospital of The Central South University, Changsha 410013, Hunan Province, China
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8
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Conley TE, White KL, Bond A, Harrison S, McLaughlin J, Lal S. Emerging uses of glucagon-like peptide 1 (GLP-1) receptor agonists following ileal resection: literature review and case examples. Frontline Gastroenterol 2023; 14:521-526. [PMID: 37854779 PMCID: PMC10579548 DOI: 10.1136/flgastro-2023-102402] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/18/2023] [Indexed: 10/20/2023] Open
Abstract
Following ileal resection, the combination of severe bile acid (BA) malabsorption, rapid small bowel transit and unrestricted upper gastrointestinal (GI) secretion results in severe diarrhoea that can prove refractory to pharmacological therapies. While established therapies, including BA sequestrants and antidiarrhoeal drugs seek to ameliorate symptoms, they do not target the underlying pathophysiological mechanisms in this patient group. Their use can also be limited by both intolerance and adverse effects. The novel use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) in these patients may allow restoration of the physiological negative feedback mechanisms lost in ileal resection and reduce diarrhoea by prolonging small bowel transit time, limiting upper GI secretions and perhaps by inhibiting hepatic BA synthesis. While recent evidence supports the use of GLP-1 RAs as a safe and effective therapy for bile acid diarrhoea (BAD), it remains uncertain whether those with severe BAD and subsequent short bowel syndrome secondary to extensive ileal resection will benefit. Here, we present three cases of severe diarrhoea secondary to extensive ileal resection in which the use of the GLP-1 RA, liraglutide, was well tolerated and resulted in an objective improvement in diarrhoeal symptoms. We further provide a narrative review of the emerging evidence base supporting the use of GLP therapies in this challenging condition.
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Affiliation(s)
| | | | - Ashley Bond
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon Harrison
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - John McLaughlin
- Gastroenterology, Salford Royal Hospitals NHS Trust, Salford, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
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9
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Kårhus ML, Knudsen E, Knop FK. Different Effects of Once-weekly and Once-daily Administered GLP-1RA Semaglutide and Liraglutide on Bile Acid Diarrhea. JCEM CASE REPORTS 2023; 1:luac004. [PMID: 37908253 PMCID: PMC10578406 DOI: 10.1210/jcemcr/luac004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Indexed: 11/02/2023]
Abstract
Bile acid diarrhea (BAD) is a socially debilitating disease. Typical symptoms include loose stools, urgency, and high stool frequency. Recently, we reported the superior efficacy of the glucagon like-peptide 1 receptor agonist (GLP-1RA) liraglutide (administered subcutaneously once daily) in reducing daily bowel movements compared with the traditionally used bile acid sequestrant colesevelam (considered the standard of care). This has generated proposals of testing longer acting and more potent GLP-1RAs for treating BAD. Here, we present a patient with severe BAD who experienced minimal effect of the once-weekly administered GLP-1RA semaglutide, but total remission of BAD symptoms during treatment with liraglutide.
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Affiliation(s)
- Martin Lund Kårhus
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
| | | | - Filip Krag Knop
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, 2730 Herlev, Denmark
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10
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Kårhus ML, Knop FK. Liraglutide versus colesevelam for treating bile acid diarrhoea - Authors' reply. Lancet Gastroenterol Hepatol 2022; 7:1075-1076. [PMID: 36370738 DOI: 10.1016/s2468-1253(22)00344-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Martin L Kårhus
- Center for Clinical Metabolic Research, Copenhagen University Hospital Herlev and Gentofte, DK-2900 Hellerup, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital Herlev and Gentofte, DK-2900 Hellerup, Denmark; Department of Clinical Medicine and Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark.
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11
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Walters JRF. Treating bile acid diarrhoea with liraglutide. Lancet Gastroenterol Hepatol 2022; 7:897-899. [PMID: 35868333 DOI: 10.1016/s2468-1253(22)00213-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Julian R F Walters
- Department of Gastroenterology, Imperial College Healthcare NHS Trust and Division of Digestive Diseases, Imperial College London, Hammersmith Hospital, London W12 0NN, UK.
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12
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Ahmed M. Functional, Diagnostic and Therapeutic Aspects of Bile. Clin Exp Gastroenterol 2022; 15:105-120. [PMID: 35898963 PMCID: PMC9309561 DOI: 10.2147/ceg.s360563] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 07/03/2022] [Indexed: 11/23/2022] Open
Abstract
Bile is a unique body fluid synthesized in our liver. Enterohepatic circulation preserves bile in our body through its efficient synthesis, transport, absorption, and reuptake. Bile is the main excretory route for bile salts, bilirubin, and potentially harmful exogenous lipophilic substances. The primary way of eliminating cholesterol is bile. Although bile has many organic and inorganic contents, bile acid is the most physiologically active component. Bile acids have a multitude of critical physiologic functions in our body. These include emulsification of dietary fat, absorption of fat and fat-soluble vitamins, maintaining glucose, lipid, and energy homeostasis, sustenance of intestinal epithelial integrity and epithelial cell proliferation, reducing inflammation in the intestine, and prevention of enteric infection due to its antimicrobial properties. But bile acids can be harmful in certain altered conditions like cholecystectomy, terminal ileal disease or resection, cholestasis, duodenogastric bile reflux, duodenogastroesophageal bile reflux, and bile acid diarrhea. Bile acids can have malignant potentials as well. There are also important diagnostic and therapeutic roles of bile acid and bile acid modulation.
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Affiliation(s)
- Monjur Ahmed
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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13
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Safety and efficacy of liraglutide versus colesevelam for the treatment of bile acid diarrhoea: a randomised, double-blind, active-comparator, non-inferiority clinical trial. Lancet Gastroenterol Hepatol 2022; 7:922-931. [DOI: 10.1016/s2468-1253(22)00198-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 12/19/2022]
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14
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Meling S, Bertoli D, Sangnes DA, Brock C, Drewes A, Ejskjaer N, Dimcevski G, Søfteland E. Diabetic Gastroenteropathy: Soothe the Symptoms or Unravel a Cure? Curr Diabetes Rev 2022; 18:e220321192412. [PMID: 34225633 DOI: 10.2174/1573399817666210322154618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/13/2021] [Indexed: 11/22/2022]
Abstract
Autonomic neuropathy in patients with diabetes mellitus, and especially complications related to gastrointestinal neuropathy, are often overlooked in the clinic. Diabetic gastroenteropathy affects every segment of the gastrointestinal tract and generates symptoms that may include nausea, early satiety, vomiting, abdominal pain, constipation, and diarrhea. Severe cases can be complicated by weight loss, dehydration, and electrolyte disturbances. The pathophysiology is complex, the diagnostics and treatment options are multidisciplinary, and there is generally a lack of evidence for the treatment options. The aims for this review are first to summarize the pathophysiology and describe possible and expected symptoms and complications.Further, we will try to supply the clinician with a straightforward tool for diagnostics, and then, we shall summarize established treatment options, including diet recommendations, pharmacological and non-pharmacological options. Finally, we will explore the multiple possibilities of novel treatment, looking at medications related to the pathophysiology of neuropathy, other manifestations of autonomic neuropathies, and symptomatic treatment for other gastrointestinal disorders, also including new knowledge of endosurgical and neuromodulatory treatment. The overall goal is to increase awareness and knowledge on this frequent diabetic complication and to provide better tools for diagnosis and treatment. Ultimately, we hope to encourage further research in this field, as there are clear shortcomings in terms of biomarkers, pathophysiology, as well as treatment possibilities. In conclusion, diagnosis and management of diabetic gastroenteropathy are challenging and often require multidisciplinary teams and multimodal therapies. Treatment options are sparse, but new pharmacological, endoscopic, and neuromodulatory techniques have shown promising results in initial studies.
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Affiliation(s)
- Sondre Meling
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Davide Bertoli
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Dag A Sangnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Asbjørn Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Sangnes DA, Dimcevski G, Frey J, Søfteland E. Diabetic diarrhoea: A study on gastrointestinal motility, pH levels and autonomic function. J Intern Med 2021; 290:1206-1218. [PMID: 34089624 DOI: 10.1111/joim.13340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic diarrhoea is a common, but poorly investigated diabetes complication. Autonomic neuropathy is a leading pathophysiological theory founded on old, small studies. Studies of gastrointestinal motility and pH levels are lacking. OBJECTIVES Using new diagnostic methods, we aimed to find out if diabetic diarrhoea was associated with alterations in gastrointestinal motility, pH levels and autonomic function. METHODS Fifty-seven patients (42 women, 46 with type 1 diabetes) were prospectively included. Symptoms were evaluated with the gastrointestinal symptom rating scale, defining ≥4 points as cases with diarrhoea. Patients scoring <4 were used as controls. We used the wireless motility capsule to measure gastrointestinal transit times, pH levels and contractility parameters. Autonomic function was assessed by measuring heart rate variability, baroreflex sensitivity and orthostatic hypotension. RESULTS Seventeen patients (30%) had diarrhoea. Compared with controls, cases had slower gastric emptying (21:46 vs. 4:14, h:min, p = 0.03) and faster colonic transit (18:37 vs. 54:25, p < 0.001). Cases had increased intraluminal pH in the antrum (2.4 vs. 1.2, p = 0.009), caecum (7.3 vs. 6.4, p = 0.008) and entire colon (7.1 vs. 6.7, p = 0.05). They also had a decreased pH difference across the pylorus (3.3 vs. 4.9, p = 0.004) and ileocaecal junction (0.6 vs 1.0, p = 0.009). The groups did not differ in autonomic function, but diastolic blood pressure drop correlated rs = -0.34 (p = 0.04) with colonic transit time. CONCLUSIONS Patients with diabetic diarrhoea had altered gastrointestinal transit and intraluminal pH levels, but minimal changes in autonomic function. Our results suggest that tests of gastrointestinal function are clinically useful in diabetic diarrhoea.
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Affiliation(s)
- Dag A Sangnes
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Jakub Frey
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eirik Søfteland
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
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16
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Hvistendahl MK, Naimi RM, Hansen SH, Rehfeld JF, Kissow H, Pedersen J, Dragsted LO, Sonne DP, Knop FK, Jeppesen PB. Bile acid-farnesoid X receptor-fibroblast growth factor 19 axis in patients with short bowel syndrome: The randomized, glepaglutide phase 2 trial. JPEN J Parenter Enteral Nutr 2021; 46:923-935. [PMID: 34287979 DOI: 10.1002/jpen.2224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The gut-liver axis and enterohepatic circulation have gained increasing attention lately. Patients with short bowel syndrome (SBS) are, in fact, human knock-out models that may assist in the understanding of bile acid synthesis and regulation. We evaluated effect of glepaglutide (a long-acting glucagon-like peptide-2 analog) on bile acid synthesis (the enterohepatic circulation of bile acids and liver biochemistry in patients with SBS). METHOD In a single-center, double-blinded, dose-finding, crossover phase 2 trial, 18 patients with SBS were randomly assigned to 2 of 3 treatment arms (0.1, 1, and 10 mg) with daily subcutaneous injections of glepaglutide for 3 weeks. The washout period between the 2 treatment periods was 4-8 weeks. Measurements were performed at baseline and at the end of each treatment period and included postprandial plasma samples for fibroblast growth factor 19 (FGF19), 7α-hydroxy-4-cholesten-3-one (C4), total excretion of fecal bile acids, gene expression of farnesoid X receptor (FXR) in intestinal mucosal biopsies, total plasma bile acids, and liver biochemistry. RESULTS Compared with baseline, the median (interquartile range) postprandial response (area under the curve 0-2h) of FGF19 increased by 150 h × ng/L (41, 195; P = 0.001) and C4 decreased by 82 h × µg/L (-169, -28; p = 0.010) in the 10-mg dose. FXR gene expression did not change in any of the groups. Alkaline phosphatase significantly decreased. CONCLUSION Glepaglutide may stimulate the bile acid/FXR/FGF19 axis, leading to increased plasma concentrations of FGF19. Thereby, glepaglutide may ameliorate the accelerated de novo bile acid synthesis and play a role in the prevention and/or treatment of intestinal failure-associated liver disease.
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Affiliation(s)
- Mark Krogh Hvistendahl
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rahim Mohammad Naimi
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Svend Høime Hansen
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens Frederik Rehfeld
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hannelouise Kissow
- Novo Nordisk Foundation Center of Basic Metabolic Research and Department of Biomedical Sciences, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Pedersen
- Novo Nordisk Foundation Center of Basic Metabolic Research and Department of Biomedical Sciences, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Ove Dragsted
- Department of Nutrition, Exercise and Sports, Science, University of Copenhagen, Frederiksberg, Denmark
| | - David Peick Sonne
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Filip Krag Knop
- Novo Nordisk Foundation Center of Basic Metabolic Research and Department of Biomedical Sciences, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Palle Bekker Jeppesen
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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17
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Zhang Z, Du Z, Liu Q, Wu T, Tang Q, Zhang J, Huang C, Huang Y, Li R, Li Y, Zhao Y, Zhang G, Zhou J, Huang H, Fang Z, He J. Glucagon-like peptide 1 analogue prevents cholesterol gallstone formation by modulating intestinal farnesoid X receptor activity. Metabolism 2021; 118:154728. [PMID: 33581130 DOI: 10.1016/j.metabol.2021.154728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/13/2021] [Accepted: 02/07/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Cholesterol gallstone disease (CGD) is a common gastrointestinal disease. Liraglutide, an analogue of glucagon-like peptide 1, has been approved to treat type 2 diabetes. Clinical studies have suggested a potential role of liraglutide in CGD. METHODS Mice were subcutaneously injected with liraglutide, then fed a lithogenic diet. Bile duct cannulation was performed to collect bile output in mice. Intestinal-specific ablation or pharmacological inhibition of farnesoid X receptor (FXR) was used to study its functions in CGD. RESULTS Liraglutide could protect mice against CGD. Liraglutide treatment increased the biliary concentration of cholesterol, phospholipids and bile acids and thereby decreased the cholesterol saturation index. The resistance to CGD conferred by liraglutide is likely a result of increased bile acid synthesis and efficient bile acid transport. The expression of a key bile acid synthetic enzyme, Cyp7a1, was significantly increased in liraglutide-treated mice. The increased expression of Cyp7a1 resulted from a relieved suppression signal of Fgf15 from the ileum. Mechanistically, liraglutide treatment altered bile acid composition and suppressed FXR activity in the ileum. Genetic ablation or pharmacological inhibition of FXR in the intestine protected mice against CGD. More importantly, intestinal FXR was required for liraglutide-mediated regulation of hepatic expression of Cyp7a1. CONCLUSION Liraglutide improved CGD by increasing bile acid secretion and decreasing cholesterol saturation index. Liraglutide attenuates the negative feedback inhibition of bile acids through inhibiting intestinal FXR activity. Our results suggest that liraglutide may represent a novel way for treating or preventing cholesterol gallstones in individuals with high risk of CGD.
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Affiliation(s)
- Zijing Zhang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Zuo Du
- Department of Toxicology and Sanitary Chemistry, School of Public Health, Tianjin Medical University, Tianjin 300070, China; Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China
| | - Qinhui Liu
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Tong Wu
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Qin Tang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Jinhang Zhang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Cuiyuan Huang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Ya Huang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Rui Li
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Yanping Li
- Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Yingnan Zhao
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Guorong Zhang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Jian Zhou
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Hui Huang
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - ZhongZe Fang
- Department of Toxicology and Sanitary Chemistry, School of Public Health, Tianjin Medical University, Tianjin 300070, China; Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China.
| | - Jinhan He
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; Department of Pharmacy, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China.
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18
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Kårhus ML, Brønden A, Lyng Forman J, Haaber A, Vilsbøll T, Sonne DP, Knop FKK. Protocol for a randomised, double-blinded, placebo-controlled, double-dummy 6-week clinical trial comparing the treatment effects of the glucagon-like peptide 1 receptor agonist liraglutide versus the bile acid sequestrant colesevelam on bile acid malabsorption. BMJ Open 2021; 11:e044711. [PMID: 33558360 PMCID: PMC7871677 DOI: 10.1136/bmjopen-2020-044711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Bile acid malabsorption (BAM) is a socially debilitating disease characterised by high stool frequency and urgency caused by a spillover of bile acids into the colon. Bile acid sequestrants (BASs) have limited therapeutic effect but represent the only available treatment option. Cases reporting total remission of BAM-related symptoms after treatment with liraglutide, a glucagon-like peptide 1 analogue, prompted us to design a clinical trial investigating the therapeutic effect of this compound in patients with BAM. METHODS AND ANALYSIS Fifty adult individuals with moderate or severe BAM as assessed by the 75selenium-homotaurocholic acid test (SeHCAT) will, after a run-in period of 10 days with no BAM treatment, be randomised to either treatment with the BAS colesevelam or liraglutide (double blinded) for 6 weeks. Daily symptom diaries and questionnaires will be filled in. Blood and faecal samples will be collected and SeHCAT will be performed at baseline, after week 3 and at end of trial. The primary endpoint is change in daily stool frequency. Secondary endpoints include changes from baseline in questionnaires, biochemistry, SeHCAT and faecal bile acid content and microbial composition. ETHICS AND DISSEMINATION The study complies with Danish and European Union legislation and is approved by the Danish Medicines Agency, the Regional Scientific Ethics Committee of the Capital Region of Denmark and the Danish Data Protection Agency. The study is monitored by the Capital Region of Denmark's good clinical practice unit. All results, positive, negative and inconclusive, will be disseminated at national and/or international scientific meetings and in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER EudraCA: 2018-003575-34; Pre-results.
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Affiliation(s)
- Martin Lund Kårhus
- Center for Clinical Metabolic Research, Gentofte University Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Brønden
- Center for Clinical Metabolic Research, Gentofte University Hospital, University of Copenhagen, Hellerup, Denmark
| | - Julie Lyng Forman
- Section of Biostatistics, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Tina Vilsbøll
- Center for Clinical Metabolic Research, Gentofte University Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - David Peick Sonne
- Center for Clinical Metabolic Research, Gentofte University Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Filip K Krag Knop
- Center for Clinical Metabolic Research, Gentofte University Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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19
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Valencia-Rodríguez A, Aquino-Matus J, Vera-Barajas A, Qi X, Méndez-Sánchez N. New therapeutic options for bile acid malabsorption diarrhea. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:695. [PMID: 31930096 PMCID: PMC6944536 DOI: 10.21037/atm.2019.09.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
| | - Jorge Aquino-Matus
- Liver Research Unit, Medica Sur Clinic and Foundation, Mexico City, Mexico
| | | | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation, Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
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