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Lupianez-Merly C, Dilmaghani S, Jencks K, Eckert D, Ryks M, Burton D, Camilleri M. Additional criteria on scintigraphic testing for diagnosis of rapid colonic transit in patients with chronic diarrhea. Neurogastroenterol Motil 2024:e14917. [PMID: 39300973 DOI: 10.1111/nmo.14917] [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: 05/01/2024] [Revised: 09/03/2024] [Accepted: 09/06/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Colonic transit (CT) measured by validated scintigraphy using 111In-labeled activated charcoal particles is summarized using geometric center (GC) of isotopic distribution in four colonic regions and stool at 24 and 48 h. Diagnosis of rapid CT is currently based on GC24 ≥4.4 in females and >4.7 in males, which lack sensitivity. Our aim was to evaluate, in patients with chronic diarrhea with normal CT by GC24 and GC48, the diagnostic utility of CT change (∆GC) relative to sex-matched normal values. METHODS We evaluated two adult patient cohorts: 701 clinical patients (1994-2023) with chronic diarrhea and 76 research participants with irritable bowel syndrome with diarrhea (N = 63) or bile acid diarrhea (BAD, N = 13). Results of ∆GC were compared to 220 healthy controls' 95th percentiles (%ile) (≥2.0 females and ≥2.2 males). In the research cohort, we also analyzed (Spearman correlation) colonic ∆GC with ascending colon emptying T1/2 (AC T1/2), average stool frequency and consistency based on a daily diary, total fecal bile acid (BA) concentration, and % primary BA in a single stool sample. KEY RESULTS Among 701 clinical patients with normal GC24, 160 (22.3%) had rapid CT based on ∆GC 95th %ile in health. Among 76 research participants, an additional 20.6% IBS-D and 23% BAD had rapid CT ∆GC. Younger age and absence of diabetes mellitus were predictive of rapid ∆GC. ∆GC significantly correlated with AC T1/2 and with fecal BA. CONCLUSIONS & INFERENCES ∆GC identified an additional 21%-23% patients with rapid colonic transit among patients with diarrhea and normal GC24.
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Affiliation(s)
- Camille Lupianez-Merly
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Saam Dilmaghani
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kara Jencks
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Deborah Eckert
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Ryks
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Duane Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Christoffersen T, Kornholt J, Riis T, Sonne DP, Klarskov N. Effect of Single-Dose Imipramine on Anal Sphincter Tone in Healthy Women: A Randomized, Placebo-Controlled Study Using Anal Acoustic Reflectometry. Int Urogynecol J 2024; 35:1873-1879. [PMID: 39167201 PMCID: PMC11420375 DOI: 10.1007/s00192-024-05890-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/14/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Despite the high prevalence of fecal incontinence, existing treatment options may be inadequate. Drugs that enhance the tone of the anal sphincter complex could potentially be an effective pharmacological approach. This study investigated the effect of the tricyclic antidepressant imipramine on anal sphincter tone in healthy women, employing anal acoustic reflectometry as the evaluating method. METHODS In a double-blind, randomized, placebo-controlled crossover study, 16 healthy female volunteers were randomized to one of two treatment sequences. The participants attended two study visits separated by at least 7 days' washout. At each visit, they received a single dose of 50 mg imipramine or matching placebo, in alternating order. We assessed the anal opening pressure under the resting state and during voluntary squeezing of the pelvic floor. Measurements were performed pre-dose and 1 h after drug administration, corresponding to the estimated time of peak plasma concentration of imipramine. RESULTS All participants completed the study. In total, 44% of the participants reported at least one adverse effect, primarily anticholinergic. Compared with placebo, imipramine increased anal opening pressure by 15.2 cmH2O (95% confidence interval [CI] 2.0-28.2 cmH2O, p = 0.03) in the resting state and 15.1 (95% CI 4.2-26.0 cmH2O, p = 0.01) cmH2O during squeezing. CONCLUSIONS The findings indicate that imipramine increases anal sphincter tone in healthy women. However, further research is required to evaluate its clinical impact on individuals with fecal incontinence. This research also demonstrates the effectiveness of using anal acoustic reflectometry for assessing pharmacological effects on anal sphincter function.
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Affiliation(s)
- Thea Christoffersen
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Jonatan Kornholt
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
- Novo Nordisk A/S, Bagsvaerd, Denmark
| | - Troels Riis
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
| | - David P Sonne
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Klarskov
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gynecology and Obstetrics, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Marasco G, Cremon C, Barbaro MR, Stanghellini V, Barbara G. Journal of Clinical Gastroenterology Lectureship Dubai 2022 : Management of Irritable Bowel Syndrome With Diarrhea. J Clin Gastroenterol 2024; 58:221-231. [PMID: 38227850 DOI: 10.1097/mcg.0000000000001964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/13/2023] [Indexed: 01/18/2024]
Abstract
Irritable bowel syndrome (IBS) with diarrhea (IBS-D) affects ~1% of the general population and is characterized by abdominal pain associated with diarrhea. IBS-D symptoms significantly impact the quality of life of patients. Major uncertainties remain regarding the optimal management of these patients. Several therapies have been investigated over the years for the treatment of IBS-D. In the initial management, commonly prescribed approaches with an effect on global IBS symptoms include a low Fermentable Oligo-, Di-, Mono-Saccharides and Polyols diet and probiotics, while antispasmodics are used for targeting abdominal pain and loperamide for diarrhea only. Additional therapeutic options for the relief of global IBS symptoms include rifaximin, 5-HT 3 antagonists, gut-directed psychological therapies, and eluxadoline, while tricyclic antidepressants can target abdominal pain and bile acid sequestrants diarrhea. Promising evidence exists for the use of mesalazine and fecal microbiota transplantation in IBS-D, although further evidence is needed for definitive conclusions regarding their efficacy.
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Affiliation(s)
- Giovanni Marasco
- IRCCS Azienda Ospedaliero Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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4
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Crawford G, Taylor R, Young D, Hatton CG. Efficacy of the Enteroadsorbent Silicol®gel in Adults with Irritable Bowel Syndrome Subtypes IBS-D or Mixed: Observational Open-Label Study. Gastroenterol Res Pract 2023; 2023:3432763. [PMID: 39263347 PMCID: PMC11390215 DOI: 10.1155/2023/3432763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/15/2023] [Accepted: 11/25/2023] [Indexed: 09/13/2024] Open
Abstract
Background Irritable bowel syndrome (IBS) is a common chronic gut-brain interaction disorder with limited effective treatment options. Intestinal adsorbents have a high adsorption capacity for gut irritants and may provide nonpharmacological alternatives. Objectives This post marketing study is aimed at providing up-to-date evidence to support the safety and efficacy in normal use of an established medical device for IBS treatment. Methods In this open-label, observational study, adults with IBS with predominant diarrhoea (IBS-D) or IBS with mixed bowel habits (IBS-M), according to Rome IV criteria, received 4 weeks of treatment with the enteroadsorbent Silicol®gel, a CE-certified, licenced, medical device containing colloidal silicic acid. Eligible participants were assessed at baseline (visit 1; in-clinic) and after 1 (visit 2; telephone), 2 (visit 3; telephone), and 4 (visit 4; in-clinic) weeks of treatment. The primary endpoint was the proportion of participants with an overall reduction in the IBS severity scoring system (IBS SSS) > 50, representing clinically meaningful improvement. Key secondary endpoints were a reduction in common IBS symptoms and improved quality of life (QoL). Results Among the 67 treated participants (IBS-D: 37; IBS-M: 30), 65 completed the study. At visit 4, 83.6% (56/67) of participants achieved a reduction in IBS SSS > 50. The mean (standard deviation [SD]) IBS SSS was 323.4 (55.7) at visit 1 and 160.3 (90.3) at visit 4 (overall change: -163.1 (101.7); 95% confidence interval [CI] 138.3, 187.9, p < 0.001). Compared with visit 1, significant reductions in the severity of all key IBS symptoms and overall improvement in QoL were observed at visit 4 (p < 0.001), with improvements observed from visits 1 and 2. Conclusions In this open-label study of participants with IBS-D and IBS-M, Silicol®gel provided clinically significant improvement in IBS symptoms, demonstrating that enteroadsorbents may be clinically beneficial in this population.
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Affiliation(s)
- Gordon Crawford
- CPS Research, McCafferty House, 99 Firhill Road, Glasgow, UK G20 7BE
| | - Rory Taylor
- CPS Research, McCafferty House, 99 Firhill Road, Glasgow, UK G20 7BE
| | - David Young
- Department of Mathematics and Statistics, University of Strathclyde, 26 Richmond Street, Glasgow, UK G1 1XH
- NHS, Greater Glasgow and Clyde, 1055 Great Western Road, Glasgow, UK G12 0XH
| | - Chris G Hatton
- FW Medical Ltd, West of Scotland Science Park, Kelvin Campus, Block 6, Glasgow, UK G20 0SP
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Alam MJ, Chen JDZ. Non-invasive neuromodulation: an emerging intervention for visceral pain in gastrointestinal disorders. Bioelectron Med 2023; 9:27. [PMID: 37990288 PMCID: PMC10664460 DOI: 10.1186/s42234-023-00130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
Gastrointestinal (GI) disorders, which extend from the esophagus to the anus, are the most common diseases of the GI tract. Among these disorders, pain, encompassing both abdominal and visceral pain, is a predominant feature, affecting the patients' quality of life and imposing a substantial financial burden on society. Pain signals originating from the gut intricately shape brain dynamics. In response, the brain sends appropriate descending signals to respond to pain through neuronal inhibition. However, due to the heterogeneous nature of the disease and its limited pathophysiological understanding, treatment options are minimal and often controversial. Consequently, many patients with GI disorders use complementary and alternative therapies such as neuromodulation to treat visceral pain. Neuromodulation intervenes in the central, peripheral, or autonomic nervous system by alternating or modulating nerve activity using electrical, electromagnetic, chemical, or optogenetic methodologies. Here, we review a few emerging noninvasive neuromodulation approaches with promising potential for alleviating pain associated with functional dyspepsia, gastroparesis, irritable bowel syndrome, inflammatory bowel disease, and non-cardiac chest pain. Moreover, we address critical aspects, including the efficacy, safety, and feasibility of these noninvasive neuromodulation methods, elucidate their mechanisms of action, and outline future research directions. In conclusion, the emerging field of noninvasive neuromodulation appears as a viable alternative therapeutic avenue for effectively managing visceral pain in GI disorders.
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Affiliation(s)
- Md Jahangir Alam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Jiande D Z Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Ford AC, Wright-Hughes A, Alderson SL, Ow PL, Ridd MJ, Foy R, Bianco G, Bishop FL, Chaddock M, Cook H, Cooper D, Fernandez C, Guthrie EA, Hartley S, Herbert A, Howdon D, Muir DP, Nath T, Newman S, Smith T, Taylor CA, Teasdale EJ, Thornton R, Farrin AJ, Everitt HA. Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2023; 402:1773-1785. [PMID: 37858323 DOI: 10.1016/s0140-6736(23)01523-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 06/30/2023] [Accepted: 07/20/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Most patients with irritable bowel syndrome (IBS) are managed in primary care. When first-line therapies for IBS are ineffective, the UK National Institute for Health and Care Excellence guideline suggests considering low- dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown, and they are infrequently prescribed in this setting. METHODS This randomised, double-blind, placebo-controlled trial (Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment [ATLANTIS]) was conducted at 55 general practices in England. Eligible participants were aged 18 years or older, with Rome IV IBS of any subtype, and ongoing symptoms (IBS Severity Scoring System [IBS-SSS] score ≥75 points) despite dietary changes and first-line therapies, a normal full blood count and C-reactive protein, negative coeliac serology, and no evidence of suicidal ideation. Participants were randomly assigned (1:1) to low-dose oral amitriptyline (10 mg once daily) or placebo for 6 months, with dose titration over 3 weeks (up to 30 mg once daily), according to symptoms and tolerability. Participants, their general practitioners, investigators, and the analysis team were all masked to allocation throughout the trial. The primary outcome was the IBS-SSS score at 6 months. Effectiveness analyses were according to intention-to-treat; safety analyses were on all participants who took at least one dose of the trial medication. This trial is registered with the ISRCTN Registry (ISRCTN48075063) and is closed to new participants. FINDINGS Between Oct 18, 2019, and April 11, 2022, 463 participants (mean age 48·5 years [SD 16·1], 315 [68%] female to 148 [32%] male) were randomly allocated to receive low-dose amitriptyline (232) or placebo (231). Intention-to-treat analysis of the primary outcome showed a significant difference in favour of low-dose amitriptyline in IBS-SSS score between groups at 6 months (-27·0, 95% CI -46·9 to -7·10; p=0·0079). 46 (20%) participants discontinued low-dose amitriptyline (30 [13%] due to adverse events), and 59 (26%) discontinued placebo (20 [9%] due to adverse events) before 6 months. There were five serious adverse reactions (two in the amitriptyline group and three in the placebo group), and five serious adverse events unrelated to trial medication. INTERPRETATION To our knowledge, this is the largest trial of a tricyclic antidepressant in IBS ever conducted. Titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes, and was safe and well tolerated. General practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial. FUNDING National Institute for Health and Care Research Health Technology Assessment Programme (grant reference 16/162/01).
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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.
| | - Alexandra Wright-Hughes
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah L Alderson
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Pei-Loo Ow
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Matthew J Ridd
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Gina Bianco
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Felicity L Bishop
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, University of Southampton, Southampton, UK
| | | | - Heather Cook
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Deborah Cooper
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Catherine Fernandez
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Elspeth A Guthrie
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Suzanne Hartley
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Amy Herbert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Howdon
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Delia P Muir
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Taposhi Nath
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sonia Newman
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Thomas Smith
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Christopher A Taylor
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Emma J Teasdale
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, University of Southampton, Southampton, UK
| | - Ruth Thornton
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amanda J Farrin
- Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Hazel A Everitt
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
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Staudacher HM, Black CJ, Teasdale SB, Mikocka-Walus A, Keefer L. Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management. Nat Rev Gastroenterol Hepatol 2023; 20:582-596. [PMID: 37268741 PMCID: PMC10237074 DOI: 10.1038/s41575-023-00794-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/04/2023]
Abstract
Irritable bowel syndrome (IBS) affects 5-10% of the global population. Up to one-third of people with IBS also experience anxiety or depression. Gastrointestinal and psychological symptoms both drive health-care use in people with IBS, but psychological comorbidity seems to be more important for long-term quality of life. An integrated care approach that addresses gastrointestinal symptoms with nutrition and brain-gut behaviour therapies is considered the gold standard. However, best practice for the treatment of individuals with IBS who have a comorbid psychological condition is unclear. Given the rising prevalence of mental health disorders, discussion of the challenges of implementing therapy for people with IBS and anxiety and depression is critical. In this Review, we draw upon our expertise in gastroenterology, nutrition science and psychology to highlight common challenges that arise when managing patients with IBS and co-occurring anxiety and depression, and provide recommendations for tailoring clinical assessment and treatment. We provide best practice recommendations, including dietary and behavioural interventions that could be applied by non-specialists and clinicians working outside an integrated care model.
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Affiliation(s)
- Heidi M Staudacher
- Food & Mood Centre, IMPACT Institute, Deakin University Geelong, Melbourne, Victoria, Australia.
| | - Christopher J Black
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Scott B Teasdale
- Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Laurie Keefer
- Department of Medicine and Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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8
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Steinmetz WE. Evaluation and management of irritable bowel syndrome. Nurse Pract 2023; 48:30-36. [PMID: 37487046 DOI: 10.1097/01.npr.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
ABSTRACT Irritable bowel syndrome (IBS) is a common diagnosis that providers encounter in primary and specialty care. IBS is characterized by chronic abdominal pain and altered bowel habits. The American College of Gastroenterology recently released an updated guideline for the evaluation and management of patients with IBS. According to the guideline, it remains important to confirm diagnosis based on criteria and lack of alarm signs; IBS should not be a diagnosis of exclusion. Management should be focused on addressing altered bowel habits and global symptoms using a multidisciplinary approach.
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Affiliation(s)
- Whitney Emerson Steinmetz
- Whitney Emerson Steinmetz is an inpatient gastroenterology nurse practitioner at Presbyterian Medical Group in Albuquerque, N.M
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9
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Shaikh SD, Sun N, Canakis A, Park WY, Weber HC. Irritable Bowel Syndrome and the Gut Microbiome: A Comprehensive Review. J Clin Med 2023; 12:jcm12072558. [PMID: 37048642 PMCID: PMC10095554 DOI: 10.3390/jcm12072558] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/10/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal tract characterized by abdominal pain and altered bowel habits. It has a prevalence of 10 to 25% in the United States and has a high disease burden, as evidenced by reduced quality of life, decreased work productivity and increased healthcare utilization and costs. IBS has been associated with several intra-intestinal and extra-intestinal conditions, including psychiatric comorbidities. Although the pathophysiology of IBS has not been fully elucidated, it involves dysregulation of communication between the brain and gut (brain–gut axis) which is associated with alterations in intestinal motility, gut permeability, visceral hypersensitivity and gut microbiota composition. The purpose of this article is to review the role the gut microbiota plays in the pathophysiology of IBS, understand factors that affect the gut microbiome and explore the microbiome as a target of treatment.
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10
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Ge L, Liu S, Li S, Yang J, Hu G, Xu C, Song W. Psychological stress in inflammatory bowel disease: Psychoneuroimmunological insights into bidirectional gut–brain communications. Front Immunol 2022; 13:1016578. [PMID: 36275694 PMCID: PMC9583867 DOI: 10.3389/fimmu.2022.1016578] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Inflammatory bowel disease (IBD), mainly including ulcerative colitis (UC) and Crohn’s disease (CD), is an autoimmune gastrointestinal disease characterized by chronic inflammation and frequent recurrence. Accumulating evidence has confirmed that chronic psychological stress is considered to trigger IBD deterioration and relapse. Moreover, studies have demonstrated that patients with IBD have a higher risk of developing symptoms of anxiety and depression than healthy individuals. However, the underlying mechanism of the link between psychological stress and IBD remains poorly understood. This review used a psychoneuroimmunology perspective to assess possible neuro-visceral integration, immune modulation, and crucial intestinal microbiome changes in IBD. Furthermore, the bidirectionality of the brain–gut axis was emphasized in the context, indicating that IBD pathophysiology increases the inflammatory response in the central nervous system and further contributes to anxiety- and depression-like behavioral comorbidities. This information will help accurately characterize the link between psychological stress and IBD disease activity. Additionally, the clinical application of functional brain imaging, microbiota-targeted treatment, psychotherapy and antidepressants should be considered during the treatment and diagnosis of IBD with behavioral comorbidities. This review elucidates the significance of more high-quality research combined with large clinical sample sizes and multiple diagnostic methods and psychotherapy, which may help to achieve personalized therapeutic strategies for IBD patients based on stress relief.
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Affiliation(s)
- Li Ge
- Shandong Provincial Key Laboratory for Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- School of Clinical and Basic Medical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Shuman Liu
- School of Clinical and Basic Medical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Sha Li
- School of Clinical and Basic Medical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Jing Yang
- Department of Gastroenterology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Guangran Hu
- School of Clinical and Basic Medical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Changqing Xu
- Department of Gastroenterology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wengang Song
- Shandong Provincial Key Laboratory for Rheumatic Disease and Translational Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- School of Clinical and Basic Medical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
- *Correspondence: Wengang Song,
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Black CJ, Paine PA, Agrawal A, Aziz I, Eugenicos MP, Houghton LA, Hungin P, Overshott R, Vasant DH, Rudd S, Winning RC, Corsetti M, Ford AC. British Society of Gastroenterology guidelines on the management of functional dyspepsia. Gut 2022; 71:1697-1723. [PMID: 35798375 PMCID: PMC9380508 DOI: 10.1136/gutjnl-2022-327737] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/21/2022] [Indexed: 01/30/2023]
Abstract
Functional dyspepsia (FD) is a common disorder of gut-brain interaction, affecting approximately 7% of individuals in the community, with most patients managed in primary care. The last British Society of Gastroenterology (BSG) guideline for the management of dyspepsia was published in 1996. In the interim, substantial advances have been made in understanding the complex pathophysiology of FD, and there has been a considerable amount of new evidence published concerning its diagnosis and classification, with the advent of the Rome IV criteria, and management. The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based diagnosis and treatment of patients. The approach to investigating the patient presenting with dyspepsia is discussed, and efficacy of drugs in FD summarised based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of pairwise and network meta-analyses. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system. These provide both the strength of the recommendations and the overall quality of evidence. Finally, in this guideline, we consider novel treatments that are in development, as well as highlighting areas of unmet need and priorities for future research.
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Affiliation(s)
- Christopher J Black
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Peter A Paine
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Anurag Agrawal
- Doncaster and Bassetlaw Hospitals NHS Trust, Doncaster, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Maria P Eugenicos
- Department of Gastroenterology, University of Edinburgh, Edinburgh, UK
| | - Lesley A Houghton
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Pali Hungin
- Primary Care and General Practice, University of Newcastle, Newcastle, UK
| | - Ross Overshott
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Dipesh H Vasant
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sheryl Rudd
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham and Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard C Winning
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham and Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham and Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alexander C Ford
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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12
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Amitriptyline at low-dose and titrated for irritable bowel syndrome as second-line treatment (The ATLANTIS trial): protocol for a randomised double-blind placebo-controlled trial in primary care. Trials 2022; 23:552. [PMID: 35804433 PMCID: PMC9264306 DOI: 10.1186/s13063-022-06492-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Irritable bowel syndrome (IBS) is a common functional bowel disorder that has a considerable impact on patient quality of life and substantial societal and health care resource costs. Current treatments are often ineffective. Tricyclic antidepressants have shown promise in secondary care populations but their effectiveness in a primary care setting remains unclear. Methods ATLANTIS is a randomised, multi-centre, parallel-group, two-arm, double-blind, placebo-controlled trial of low-dose amitriptyline as a second-line treatment for IBS in primary care. Participants will be invited by letter, or recruited opportunistically, from general practices in three regions of England (West Yorkshire, Wessex, and West of England) and screened for eligibility. A total of 518 adult patients with IBS, who are symptomatic despite first-line therapies, will be randomised 1:1 to amitriptyline or identical placebo for 6 months. Treatment will commence at a dose of 10 mg (or one placebo tablet) daily at night, with dose titration up to a maximum of 30 mg at night, depending on side effects and response to treatment. Participant-reported assessments will be conducted at baseline and 3, 6, and 12 months post-randomisation. The primary objective is to determine the effectiveness of amitriptyline, compared with placebo, in improving participant-reported global symptoms of IBS at 6 months (using the IBS Severity Scoring System). Secondary outcomes include relief of IBS symptoms, effect on IBS-associated somatic symptoms (Patient Health Questionnaire-12), anxiety and depression (Hospital Anxiety and Depression Scale), ability to work and participate in other activities (Work and Social Adjustment Scale), acceptability and tolerability of treatment, self-reported health care use, health-related quality of life (EQ-5D-3L), and cost-effectiveness. A nested, qualitative study will explore patient and general practitioner experiences of treatments and trial participation, including acceptability, adherence, unanticipated effects, and implications for wider use of amitriptyline for IBS in primary care. Discussion Determining the clinical and cost-effectiveness of low-dose amitriptyline as a second-line treatment for IBS in primary care will provide robust evidence to inform management decisions. Trial registration ISRCTN ISRCTN48075063
. Registered on 7th June 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06492-6.
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13
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Song KH. Antispasmodics. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2022. [DOI: 10.7704/kjhugr.2022.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Antispasmodics are effective in reducing abdominal pain associated with visceral organs, bloating, and bowel habit changes and are commonly used as “on-demand therapy.” A relatively regular intake of antispasmodics may help patients with functional gastrointestinal disease exacerbation. Irritable bowel syndrome and functional dyspepsia are representative functional gastrointestinal diseases with abdominal pain and bloating as the main symptoms. Most of the clinical data on antispasmodics are obtained from studies on functional gastrointestinal diseases including irritable bowel syndrome. Antispasmodics can be safely used for prolonged periods without serious adverse effects; however, different antispasmodics have different anticholinergic potencies. Antispasmodics with strong anticholinergic effects should be prescribed with caution to patients with glaucoma or prostatic hypertrophy-induced dysuria and to those driving vehicles, operating machinery, or receiving other anticholinergic drugs in combination. Antispasmodics meeting US Food and Drug Administration guidelines for efficacy, those showing relatively consistent efficacy in different trials, and those with prokinetic effects are currently available. Many patients with upper gastrointestinal symptoms have overlapping functional gastrointestinal disorders and may require antispasmodic drugs. Alternatively, tricyclic antidepressant or ramosetron use can be considered in patients with irritable bowel syndrome. This review summarizes the clinical data and characteristics of antispasmodics, particularly those available in South Korea.
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14
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Wu KC, Cao S, Weaver CM, King NJ, Patel S, Kingman H, Sellmeyer DE, McCauley K, Li D, Lynch SV, Kim TY, Black DM, Shafer MM, Özçam M, Lin DL, Rogers SJ, Stewart L, Carter JT, Posselt AM, Schafer AL. Prebiotic to Improve Calcium Absorption in Postmenopausal Women After Gastric Bypass: A Randomized Controlled Trial. J Clin Endocrinol Metab 2022; 107:1053-1064. [PMID: 34888663 PMCID: PMC8947782 DOI: 10.1210/clinem/dgab883] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The adverse skeletal effects of Roux-en-Y gastric bypass (RYGB) are partly caused by intestinal calcium absorption decline. Prebiotics, such as soluble corn fiber (SCF), augment colonic calcium absorption in healthy individuals. OBJECTIVE We tested the effects of SCF on fractional calcium absorption (FCA), biochemical parameters, and the fecal microbiome in a post-RYGB population. METHODS Randomized, double-blind, placebo-controlled trial of 20 postmenopausal women with history of RYGB a mean 5 years prior; a 2-month course of 20 g/day SCF or maltodextrin placebo was taken orally. The main outcome measure was between-group difference in absolute change in FCA (primary outcome) and was measured with a gold standard dual stable isotope method. Other measures included tolerability, adherence, serum calciotropic hormones and bone turnover markers, and fecal microbial composition via 16S rRNA gene sequencing. RESULTS Mean FCA ± SD at baseline was low at 5.5 ± 5.1%. Comparing SCF to placebo, there was no between-group difference in mean (95% CI) change in FCA (+3.4 [-6.7, +13.6]%), nor in calciotropic hormones or bone turnover markers. The SCF group had a wider variation in FCA change than placebo (SD 13.4% vs 7.0%). Those with greater change in microbial composition following SCF treatment had greater increase in FCA (r2 = 0.72, P = 0.05). SCF adherence was high, and gastrointestinal symptoms were similar between groups. CONCLUSION No between-group differences were observed in changes in FCA or calciotropic hormones, but wide CIs suggest a variable impact of SCF that may be due to the degree of gut microbiome alteration. Daily SCF consumption was well tolerated. Larger and longer-term studies are warranted.
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Affiliation(s)
- Karin C Wu
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
- Endocrine Research Unit, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
| | - Sisi Cao
- Department of Nutrition Science, Purdue University, West Lafayette, IN 47907, USA
- Department of Human Sciences, the Ohio State University, Columbus, OH 43210, USA
| | - Connie M Weaver
- Department of Nutrition Science, Purdue University, West Lafayette, IN 47907, USA
| | - Nicole J King
- Endocrine Research Unit, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
| | - Sheena Patel
- California Pacific Medical Center Research Institute, San Francisco, CA 94107, USA
| | - Hillary Kingman
- Endocrine Research Unit, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
| | - Deborah E Sellmeyer
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Kathryn McCauley
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Danny Li
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Susan V Lynch
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Tiffany Y Kim
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
- Endocrine Research Unit, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
| | - Dennis M Black
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143, USA
| | - Martin M Shafer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Mustafa Özçam
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Din L Lin
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Stanley J Rogers
- Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Lygia Stewart
- Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
- Surgical Services, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
| | - Jonathan T Carter
- Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Andrew M Posselt
- Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Anne L Schafer
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
- Endocrine Research Unit, San Francisco Veterans Affairs Health Care System, San Francisco, CA 94121, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143, USA
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15
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Hammer HF, Fox MR, Keller J, Salvatore S, Basilisco G, Hammer J, Lopetuso L, Benninga M, Borrelli O, Dumitrascu D, Hauser B, Herszenyi L, Nakov R, Pohl D, Thapar N, Sonyi M. European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus. United European Gastroenterol J 2022; 10:15-40. [PMID: 34431620 PMCID: PMC8830282 DOI: 10.1002/ueg2.12133] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Measurement of breath hydrogen (H2 ) and methane (CH4 ) excretion after ingestion of test-carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline. METHODS This consensus-based clinical practice guideline defines the clinical indications, performance, and interpretation of H2 -CH4 -breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria. RESULTS The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro-cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H2 -CH4 -breath tests in these indications and recommends approaches to mitigate these issues. CONCLUSION This clinical practice guideline should facilitate pan-European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.
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Affiliation(s)
- Heinz F. Hammer
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMedical UniversityGrazAustria
| | - Mark R. Fox
- Centre for Integrative GastroenterologyDigestive Function: BaselLaboratory and Clinic for Motility Disorders and Functional Gastrointestinal DiseasesKlinik ArlesheimArlesheimSwitzerland
- Division of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Jutta Keller
- Department of Internal MedicineIsraelitic HospitalAcademic Hospital of the University of HamburgHamburgGermany
| | - Silvia Salvatore
- Pediatric DepartmentHospital “F. Del Ponte”University of InsubriaVareseItaly
| | - Guido Basilisco
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanoItaly
| | - Johann Hammer
- Department of Gastroenterology and HepatologyUniversity Hospital of Internal Medicine 3Medical University of ViennaViennaAustria
| | - Loris Lopetuso
- UOC Medicina Interna e GastroenterologiaDipartimento di Scienze Mediche e ChirurgicheFondazione Policlinico Universitario A. Gemelli IRCCSRomeItalia
- Department of Medicine and Ageing Sciences“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
| | - Dan Dumitrascu
- Department of GastroenterologyClinica Medicala 2Cluj‐NapocaRomania
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and NutritionKidZ Health Castle UZ BrusselBrusselsBelgium
| | - Laszlo Herszenyi
- Department of GastroenterologyMedical CentreHungarian Defence ForcesBudapestHungary
| | - Radislav Nakov
- Clinic of GastroenterologyTsaritsa Yoanna University HospitalMedical University of SofiaSofiaBulgaria
| | - Daniel Pohl
- Division of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
- Gastroenterology, Hepatology and Liver TransplantQueensland Children's HospitalBrisbaneAustralia
| | - Marc Sonyi
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMedical UniversityGrazAustria
- Clinic for General Medicine, Gastroenterology, and Infectious DiseasesAugustinerinnen HospitalCologneGermany
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Lambarth A, Zarate-Lopez N, Fayaz A. Oral and parenteral anti-neuropathic agents for the management of pain and discomfort in irritable bowel syndrome: A systematic review and meta-analysis. Neurogastroenterol Motil 2022; 34:e14289. [PMID: 34755926 DOI: 10.1111/nmo.14289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a highly prevalent and economically burdensome condition; and pain is often the most unpleasant, disruptive, and difficult-to-treat symptom. Visceral hypersensitivity is a common feature driving pain in IBS, suggesting that neuropathic mechanisms may be implicated. We conducted a systematic review of available evidence to examine the role of anti-neuropathic medicines in the management of pain in IBS. METHODS We systematically searched scientific repositories for trials investigating conventional oral, and/or parenteral, pharmaceutical antineuropathic treatments in patients with IBS. We summarized key participant characteristics, outcomes related to pain (primary outcome), and selected secondary outcomes. KEY RESULTS We included 13 studies (n = 629 participants): six investigated amitriptyline, three duloxetine, three pregabalin, and one gabapentin. There was considerable methodological and statistical heterogeneity, so we performed a narrative synthesis and limited meta-analysis. Amitriptyline was most extensively studied, though only in diarrhea-predominant patients. In individual trials, amitriptyline, pregabalin and gabapentin generally appeared beneficial for pain outcomes. While duloxetine studies tended to report improvements in pain, all were un-controlled trials with high risk of bias. Meta-analysis of three studies (n = 278) yielded a pooled relative-risk of 0.50 (95%CI 0.38-0.66) for not improving with anti-neuropathic agent vs control. We did not identify any eligible studies investigating the role of parenteral anti-neuropathics. CONCLUSIONS AND INFERENCES Anti-neuropathic analgesics may improve pain in IBS, and deserve further, high-quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Investigation of amitriptyline's efficacy in non-diarrhea-predominant subtypes is currently lacking, and we recommend particular caution for its use in IBS-C.
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Affiliation(s)
- Andrew Lambarth
- University College London Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Natalia Zarate-Lopez
- University College London Hospital Gastrointestinal Physiology Unit, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Alan Fayaz
- University College Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
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Brito HP, Sugai B, Chaves FT, Ide E, Rodrigues RA, Chaves DM. GASTRIC RESIDUAL VOLUME FACTORS AFTER BOWEL PREPARATION WITH MANNITOL EXPRESS. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:180-184. [PMID: 34378651 DOI: 10.1590/s0004-2803.202100000-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bowel preparation with mannitol is a well-established method in Brazil. However, factors that interfere with the gastric emptying time period are yet to be known. Knowing these factors may favor the examination scheduling logistics and the individualized orientation for each patient. OBJECTIVE Know the factors that can contribute to the gastric emptying time after intestinal preparation with express mannitol. METHODS This is a prospective observational study to know factors that may contribute on the gastric emptying timing: predominant type of diet, comorbidities, medication usage, previous surgeries, number of evacuation per week, bearer of bowel obstipation, fecal type, diet type, number of evacuations after the home usage of bisacodyl before the ingestion of mannitol and number of evacuations after the ingestion of mannitol until reaching a proper bowel preparation. Before starting the colonoscopy exam, an upper digestive endoscopy exam was made to aspirate the gastric content. RESULTS Sample was composed of 103 patients, 55 (53.4%) women, medium age 61 (±12.1) years, medium weight 75.3 (±14.1) kg, medium height 1.7 (±10) m and medium BMI of 26.6 (±3.9) kg/m2. Average gastric residual volume was 120.9 (0-900) mL. Gastric residual volume (GRV) below 100 mL (GRV ≤100 mL) occurred in 45 (43.6%) patients, 24 (53.3%) women, medium age of 61.0 years and medium BMI of 26.7 kg/m2. Gastric residual volume above 100 mL (GRV >100 mL) occurred on 58 (56.3%) patients, 29 (50%) women, medium age of 61.0 years and medium BMI of 26.2 kg/m2. Comparing both groups, average fasting time period after the ingestion of mannitol was significantly higher on the group with GRV ≤100 mL than group with GRV >100 mL, 123.1 (60-246) vs 95.3 (55-195) minutes, respectively. There was also statistical significance concerning the usage of ezetimibe 6 (13.7%) in the group with GRV ≤100 mL and statistical significance in the group with GRV >100 mL concerning the usage of paroxetine 3 (6.7%) and tadalafil 3 (6.7%) and surgical history of prostatectomy 3 (6.7%) and bridle withdrawal 3 (6.7%). CONCLUSION We may conclude in this study that the usage of ezetimibe and fasting above 2 hours after the ingestion of mannitol decrease significantly the incidence of a GRV >100 mL. The usage of paroxetine, tadalafil and surgical history of prostatectomy or bridle withdrawal may contribute to increase de incidence of a GRV >100 mL.
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Affiliation(s)
| | - Beatriz Sugai
- Fleury Medicina e Saúde, Departamento de Endoscopia, São Paulo, SP, Brasil
| | | | - Edson Ide
- Fleury Medicina e Saúde, Departamento de Endoscopia, São Paulo, SP, Brasil
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18
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Serotonergic receptor gene polymorphism and response to selective serotonin reuptake inhibitors in ethnic Malay patients with first episode of major depressive disorder. THE PHARMACOGENOMICS JOURNAL 2021; 21:498-509. [PMID: 33731884 DOI: 10.1038/s41397-021-00228-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 01/29/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Abstract
The polymorphisms of the 5HTR1A and 5HTR2A receptor genes (rs6295C/G and rs6311G/A) have been evaluated for association with SSRI treatment outcome in various populations with different results. The present study was carried out to determine the association between genotypes of HTR1A-rs6295 and HTR2A-rs6311 with SSRI treatment outcome among the ethnic Malay patients diagnosed with first-episode major depressive disorder (MDD). The patients were recruited from four tertiary hospitals in the Klang Valley region of Malaysia. Predefined efficacy phenotypes based on 25% (partial early response) and 50% (clinical efficacy response) reduction in Montgomery Asberg Depression Rating Scale-self Rated score (MADRS-S) were adopted for assessment of treatment efficacy in this study. Self-reporting for adverse effects (AE) was documented using the Patient Rated Inventory of Side Effect (PRISE) after treatment with SSRI for up to 6 weeks. Adjusted binary logistic regression between genotypes of the polymorphism obtained using sequencing technique with the treatment outcome phenotypes was performed. The 142 patients recruited were made up of 96 females (67.6%) and 46 males (32.4%). Clinical efficacy and Partial early response phenotypes were not significantly associated with genotypes of HTR1A and HTR2A polymorphism. The GG genotype of HTR2A polymorphism has decreased odds for dizziness (CNS) and increased odds for poor concentration. The GA genotype increases the odd for excessive sweating, diarrhoea, constipation and blurred vision. The CC genotype of HTR1A-rs6295 decreases the odd for nausea/vomiting and increases the odd for anxiety. Thus, some genotypes of HTR1A and HTR2A polymorphism were associated with SSRI treatment outcomes in ethnic Malay MDD patients.
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19
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Vasant DH, Paine PA, Black CJ, Houghton LA, Everitt HA, Corsetti M, Agrawal A, Aziz I, Farmer AD, Eugenicos MP, Moss-Morris R, Yiannakou Y, Ford AC. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut 2021; 70:1214-1240. [PMID: 33903147 DOI: 10.1136/gutjnl-2021-324598] [Citation(s) in RCA: 204] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome (IBS) remains one of the most common gastrointestinal disorders seen by clinicians in both primary and secondary care. Since publication of the last British Society of Gastroenterology (BSG) guideline in 2007, substantial advances have been made in understanding its complex pathophysiology, resulting in its re-classification as a disorder of gut-brain interaction, rather than a functional gastrointestinal disorder. Moreover, there has been a considerable amount of new evidence published concerning the diagnosis, investigation and management of IBS. The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based management of patients. One of the strengths of this guideline is that the recommendations for treatment are based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of trial-based and network meta-analyses assessing the efficacy of dietary, pharmacological and psychological therapies in treating IBS. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system, summarising both the strength of the recommendations and the overall quality of evidence. Finally, this guideline identifies novel treatments that are in development, as well as highlighting areas of unmet need for future research.
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Affiliation(s)
- Dipesh H Vasant
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Peter A Paine
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK.,Gastroenterology, Salford Royal Foundation Trust, Salford, UK
| | - Christopher J Black
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Lesley A Houghton
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.,Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Hazel A Everitt
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Anurag Agrawal
- Gastroenterology, Doncaster and Bassetlaw Hospitals NHS Trust, Armthorpe Road, Doncaster, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Adam D Farmer
- Department of Gastroenterology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.,School of Medicine, Keele University, Keele, UK
| | - Maria P Eugenicos
- Department of Gastroenterology, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Rona Moss-Morris
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Yan Yiannakou
- Department of Gastroenterology, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK .,Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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20
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Staudacher HM, Mikocka-Walus A, Ford AC. Common mental disorders in irritable bowel syndrome: pathophysiology, management, and considerations for future randomised controlled trials. Lancet Gastroenterol Hepatol 2021; 6:401-410. [PMID: 33587890 DOI: 10.1016/s2468-1253(20)30363-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 12/17/2022]
Abstract
The frequent co-occurrence of irritable bowel syndrome and the common mental disorders of anxiety and depression is well established. A range of biological and psychosocial disease mechanisms are common to both disorders, many of which contribute to a dysregulated gut-brain axis. Clinical and subthreshold psychological comorbidity adds to the functional impairment and disease burden in individuals with irritable bowel syndrome. Progress is being made with regard to understanding irritable bowel syndrome in the clinical setting from a biopsychosocial perspective. However, until now, most trials of irritable bowel syndrome treatment still consider the disease as a gut disorder in isolation, which leaves major gaps in knowledge about disease-disease interactions and treatment outcomes in irritable bowel syndrome. In this Viewpoint, we review the epidemiology, pathophysiology, and management of anxiety and depression in individuals with irritable bowel syndrome. We also provide methodological recommendations for future randomised controlled trials and outline guidance for research that better incorporates psychiatric comorbidity into its design, with a view to improve treatment outcomes for individuals with irritable bowel syndrome.
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Affiliation(s)
- Heidi M Staudacher
- IMPACT, Food & Mood Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia.
| | | | - 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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21
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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: 356] [Impact Index Per Article: 118.7] [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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22
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Wong MYW, Hebbard G, Gibson PR, Burgell RE. Chronic constipation and abdominal pain: Independent or closely interrelated symptoms? J Gastroenterol Hepatol 2020; 35:1294-1301. [PMID: 31900961 DOI: 10.1111/jgh.14970] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/20/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023]
Abstract
Constipation is both a symptom and a disorder, seen in both functional constipation and irritable bowel syndrome with constipation predominance (IBS-C). Despite the Rome IV criteria distinguishing between these conditions, they share many therapeutic approaches. This review aims to explore the relationship between constipation and abdominal pain and assess the evidence surrounding whether laxation improves abdominal pain and whether such a response to laxation differs between IBS-C and functional constipation. In patients with functional constipation, increasing frequency of bowel motions by laxatives regardless of mechanism of action is associated with reductions in the severity of abdominal pain, supporting the role of constipation as a contributor to abdominal discomfort. In patients with IBS-C, evidence from systematic reviews indicates that abdominal pain is driven by factors additional to constipation alone and that visceral analgesic modulation is also needed to optimize pain. Changing definitions of IBS-C and heterogeneity in clinical trial design including endpoints have raised uncertainty about the comparative ability of older laxatives without known neuromodulatory effects to improve chronic abdominal pain compared with new secretagogues and prokinetics for the management of IBS-C. While it is known that abdominal pain is associated with constipation and laxation contributes to relief of that pain, it remains unproven whether proposed visceral analgesic properties of new laxatives provide greater pain relief than laxation alone. However, it is likely that the response to laxation in IBS-C is only part of the puzzle.
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Affiliation(s)
- May Y W Wong
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, The Royal Melbourne Hospital and Melbourne University, Melbourne, Victoria, Australia
| | - Geoffrey Hebbard
- Department of Gastroenterology, The Royal Melbourne Hospital and Melbourne University, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Rebecca E Burgell
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
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23
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Austhof E, Schaefer K, Faulkner J, Bach L, Riddle M, Pogreba-Brown K. Knowledge and practices of primary care physicians or general practitioners treating post-infectious Irritable Bowel Syndrome. BMC Gastroenterol 2020; 20:159. [PMID: 32450813 PMCID: PMC7249359 DOI: 10.1186/s12876-020-01305-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023] Open
Abstract
Background Post-infectious Irritable Bowel Syndrome (PI-IBS) is a functional bowel disorder which has significant impacts to a patient’s quality of life. No IBS-specific biomarker or treatment regimen for PI-IBS currently exists, therefore understanding practice patterns and variance is of interest. Methods This online survey of primary care physicians and general practitioners in the USA aimed to understand the knowledge and treatment of PI-IBS within the physician’s current practice. Summary statistics are provided with a commentary on implications for practices and treatment of PI-IBS. Results Most physician survey respondents (n = 50) were aware of PI-IBS, but less than half discussed this condition as a possible outcome in their patients with a recent gastrointestinal infection. Most physicians indicated that they would treat the patients themselves with a focus on managing IBS through different treatment modalities based on severity. Treatment for PI-IBS followed IBS recommendations, but most physicians also prescribed a probiotic for therapy. Physicians estimated that 4 out of 10 patients who develop PI-IBS will have life-long symptoms and described significant impacts to their patient’s quality of life. Additionally, physicians estimated a significant financial burden for PI-IBS patients, ranging from $100–1000 (USD) over the course of their illness. Most physicians agreed that they would use a risk score to predict the probability of their patients developing PI-IBS, if available. Conclusions While this survey is limited due to sample size, physician knowledge and treatment of PI-IBS was consistent across respondents. Overall, the physicians identified significant impacts to patient’s quality of life due to PI-IBS.
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Affiliation(s)
- Erika Austhof
- Department of Epidemiology & Biostatistics, University of Arizona, Mel and Enid Zuckerman College of Public Health, 1295 N Martin Ave, PO Box 245211, Tucson, 85721, AZ, USA.
| | - Kenzie Schaefer
- Department of Epidemiology & Biostatistics, University of Arizona, Mel and Enid Zuckerman College of Public Health, 1295 N Martin Ave, PO Box 245211, Tucson, 85721, AZ, USA.,College of Medicine, University of Arizona, 1501 N Campbell Ave, PO Box 245017, Tucson, 85724, AZ, USA
| | - Jaime Faulkner
- College of Medicine, University of Arizona, 1501 N Campbell Ave, PO Box 245017, Tucson, 85724, AZ, USA
| | - Laura Bach
- Division of Gastroenterology and Hepatology, College of Medicine, University of Arizona, 1501 N Campbell Ave, PO Box 245028, Tucson, 85724, AZ, USA
| | - Mark Riddle
- School of Medicine, University of Nevada Reno, 1664 N Virginia Street, Reno, 89557, NV, USA
| | - Kristen Pogreba-Brown
- Department of Epidemiology & Biostatistics, University of Arizona, Mel and Enid Zuckerman College of Public Health, 1295 N Martin Ave, PO Box 245211, Tucson, 85721, AZ, USA
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24
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Mikocka-Walus A, Ford AC, Drossman DA. Antidepressants in inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2020; 17:184-192. [PMID: 32071420 DOI: 10.1038/s41575-019-0259-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
Gut-brain dysregulation has been recognized by the scientific community as being crucial to the understanding of chronic gastrointestinal conditions, and this has translated into the practice of a newly established discipline, psychogastroenterology. Along with psychotherapy, antidepressants (a subtype of central neuromodulators) have been proposed as treatments for gut-brain disorders that might benefit both psychological and gastrointestinal health. Antidepressants have been found to be effective for the treatment of comorbid anxiety and depression, pain and impaired sleep. Although the efficacy of antidepressants is well established in disorders of gut-brain interaction (DGBI), evidence is only now emerging in IBD. This Perspective discusses the use of antidepressants in DGBI and IBD, focusing on how what we have learnt about the role of antidepressants in DGBI could be applied to help optimize the management of IBD.
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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
| | - Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA.,Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, NC, USA
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25
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Moayyedi P, Andrews CN, MacQueen G, Korownyk C, Marsiglio M, Graff L, Kvern B, Lazarescu A, Liu L, Paterson WG, Sidani S, Vanner S. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol 2019; 2:6-29. [PMID: 31294724 PMCID: PMC6507291 DOI: 10.1093/jcag/gwy071] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) is one of the most common gastrointestinal (GI) disorders, affecting about 10% of the general population globally. The aim of this consensus was to develop guidelines for the management of IBS. METHODS A systematic literature search identified studies on the management of IBS. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a multidisciplinary group of clinicians and a patient. RESULTS Consensus was reached on 28 of 31 statements. Irritable bowel syndrome is diagnosed based on symptoms; serological testing is suggested to exclude celiac disease, but routine testing for C-reactive protein (CRP), fecal calprotectin or food allergies is not recommended. A trial of a low fermentable oligosaccharides, disaccharides, monosaccharides, polyols (FODMAP) diet is suggested, while a gluten-free diet is not. Psyllium, but not wheat bran, supplementation may help reduce symptoms. Alternative therapies such as peppermint oil and probiotics are suggested, while herbal therapies and acupuncture are not. Cognitive behavioural therapy and hypnotherapy are suggested psychological therapies. Among the suggested or recommended pharmacological therapies are antispasmodics, certain antidepressants, eluxadoline, lubiprostone, and linaclotide. Loperamide, cholestyramine and osmotic laxatives are not recommended for overall IBS symptoms. The nature of the IBS symptoms (diarrhea-predominant or constipation-predominant) should be considered in the choice of pharmacological treatments. CONCLUSIONS Patients with IBS may benefit from a multipronged, individualized approach to treatment, including dietary modifications, psychological and pharmacological therapies.
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Affiliation(s)
- Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | | | - Glenda MacQueen
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Christina Korownyk
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lesley Graff
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brent Kvern
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Louis Liu
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - William G Paterson
- Division of Gastroenterology, Queen’s University, Kingston, Ontario, Canada
| | - Sacha Sidani
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Stephen Vanner
- Division of Gastroenterology, Queen’s University, Kingston, Ontario, Canada
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26
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Ford AC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P. Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-Analysis. Am J Gastroenterol 2019; 114:21-39. [PMID: 30177784 DOI: 10.1038/s41395-018-0222-5] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Irritable bowel syndrome (IBS) is a chronic functional bowel disorder that is thought to be due to a disorder of brain-gut function. Drugs acting centrally, such as antidepressants, and psychological therapies may, therefore, be effective. METHODS We updated a previous systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, PsychINFO, and the Cochrane Controlled Trials Register were searched (up to July 2017). Trials recruiting adults with IBS, which compared antidepressants versus placebo, or psychological therapies versus control therapy or "usual management" were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). RESULTS The search strategy identified 5316 citations. Fifty-three RCTs, reported in 51 separate articles, were eligible for inclusion: 17 compared antidepressants with placebo, 35 compared psychological therapies with control therapy or "usual management", and one compared both psychological therapy and antidepressants with placebo. Four of the trials of psychological therapies, and one of the RCTs of antidepressants, were identified since our previous meta-analysis. The RR of IBS symptoms not improving with antidepressants versus placebo was 0.66 (95% CI 0.57-0.76), with similar treatment effects for both tricyclic antidepressants and SSRIs, although with heterogeneity between RCTs of the latter (I(2) = 49%, P = 0.07). The RR of symptoms not improving with psychological therapies was 0.69 (95% CI 0.62-0.76). Cognitive behavioral therapy, relaxation therapy, multi-component psychological therapy, hypnotherapy, and dynamic psychotherapy were all beneficial when data from two or more RCTs were pooled. There was significant heterogeneity between studies (I(2) = 69%, P < 0.001) and significant funnel plot asymmetry. There were also issues regarding trial design, including lack of blinding. CONCLUSIONS Antidepressants are efficacious in reducing symptoms in IBS patients. Psychological therapies also appear to be effective treatments for IBS, although there are limitations in the quality of the evidence, and treatment effects may be overestimated as a result.
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Affiliation(s)
- Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Lucinda A Harris
- Division of Gastroenterology and Hepatology, Mayo School of Medicine, Scottsdale, AZ, USA
| | - 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, TX, USA
| | - Paul Moayyedi
- Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, ON, Canada
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27
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Camilleri M. Management Options for Irritable Bowel Syndrome. Mayo Clin Proc 2018; 93:1858-1872. [PMID: 30522596 PMCID: PMC6314474 DOI: 10.1016/j.mayocp.2018.04.032] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/23/2018] [Accepted: 04/27/2018] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) is associated with diverse pathophysiologic mechanisms. These mechanisms include increased abnormal colonic motility or transit, intestinal or colorectal sensation, increased colonic bile acid concentration, and superficial colonic mucosal inflammation, as well as epithelial barrier dysfunction, neurohormonal up-regulation, and activation of secretory processes in the epithelial layer. Novel approaches to treatment include lifestyle modification, changes in diet, probiotics, and pharmacotherapy directed to the motility, sensation, and intraluminal milieu of patients with IBS. Despite recent advances, there is a need for development of new treatments to relieve pain in IBS without deleterious central or other adverse effects.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program and Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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28
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Simrén M, Tack J. New treatments and therapeutic targets for IBS and other functional bowel disorders. Nat Rev Gastroenterol Hepatol 2018; 15:589-605. [PMID: 29930260 DOI: 10.1038/s41575-018-0034-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Functional bowel disorders (FBDs) are a spectrum of disorders characterized by combinations of symptoms attributable to the lower gastrointestinal tract. Most current first-line therapies for IBS and other FBDs target the predominant symptom and mainly affect one symptom in the symptom complex. Additional broadly effective treatment alternatives targeting the entire symptom complex are needed. New drugs for FBDs (such as lubiprostone, linaclotide, plecanatide, prucalopride, eluxadoline and rifaximin) target key mechanisms in the pathophysiology of these disorders and improve both the abnormal bowel habit and other key symptoms, such as abdominal pain and bloating. The current development of new treatment alternatives is focusing on different aspects of the complex pathophysiology of IBS and other FBDs: gut microenvironment (via diet and modulation of gut microbiota), enterohepatic circulation of bile acids, gastrointestinal secretion, motility and sensation, gut-brain interactions, gut barrier function and the immune system within the gastrointestinal tract. Studies also suggest that personalized treatment of IBS and other FBDs is possible using various diagnostic markers.
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Affiliation(s)
- Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
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29
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Bonilla S, Nurko S. Focus on the use of antidepressants to treat pediatric functional abdominal pain: current perspectives. Clin Exp Gastroenterol 2018; 11:365-372. [PMID: 30310301 PMCID: PMC6166750 DOI: 10.2147/ceg.s146646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Chronic abdominal pain is frequently encountered in pediatric practice. A large proportion of cases meet Rome criteria for abdominal pain-functional gastrointestinal disorders (AP-FGIDs). These disorders are costly and, in some cases, lead to impairment of daily functioning and overall quality of life. Pathophysiologic mechanisms include early stressful events, visceral hypersensitivity, dysmotility, changes in intestinal microbiota, and altered central nervous system processing. They are considered disorders of the brain-gut interaction. The diagnosis is made on clinical grounds using symptom-based criteria (Rome criteria). Anxiety and depressive symptoms are more prevalent in patients with AP-FGIDs. Therefore, attention has been directed to the use of neuromodulators as potential interventions for AP-FGIDs. Antidepressants are one type of neuromodulators, and one of the most studied drugs for the management of AP-FGIDs in adult and pediatric population. Data available in pediatric population have significant limitations including nonuniform methodology with different study designs and primary endpoints. Evidence of the efficacy of antidepressants in the management of pediatric AP-FGIDs is not consistent. There is an urgent need for well-designed randomized clinical trials using age-appropriate validated outcome measures. Careful consideration must be given to adverse effects, particularly increased suicidal ideation.
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Affiliation(s)
- Silvana Bonilla
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital. Boston, MA, USA,
| | - Samuel Nurko
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital. Boston, MA, USA,
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30
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Ford AC, Moayyedi P, Chey WD, Harris LA, Lacy BE, Saito YA, Quigley EMM. American College of Gastroenterology Monograph on Management of Irritable Bowel Syndrome. Am J Gastroenterol 2018; 113:1-18. [PMID: 29950604 DOI: 10.1038/s41395-018-0084-x] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds and Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Paul Moayyedi
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - William D Chey
- Division of Gastroenterology, Department of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX, USA.
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31
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Song KH, Jung HK, Kim HJ, Koo HS, Kwon YH, Shin HD, Lim HC, Shin JE, Kim SE, Cho DH, Kim JH, Kim HJ. Clinical Practice Guidelines for Irritable Bowel Syndrome in Korea, 2017 Revised Edition. J Neurogastroenterol Motil 2018; 24:197-215. [PMID: 29605976 PMCID: PMC5885719 DOI: 10.5056/jnm17145] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/11/2018] [Accepted: 02/27/2018] [Indexed: 12/12/2022] Open
Abstract
In 2011, the Korean Society of Neurogastroenterology and Motility (KSNM) published clinical practice guidelines on the management of irritable bowel syndrome (IBS) based on a systematic review of the literature. The KSNM planned to update the clinical practice guidelines to support primary physicians, reduce the socioeconomic burden of IBS, and reflect advances in the pathophysiology and management of IBS. The present revised version of the guidelines is in continuity with the previous version and targets adults diagnosed with, or suspected to have, IBS. A librarian created a literature search query, and a systematic review was conducted to identify candidate guidelines. Feasible documents were verified based on predetermined inclusion and exclusion criteria. The candidate seed guidelines were fully evaluated by the Guidelines Development Committee using the Appraisal of Guidelines for Research and Evaluation II quality assessment tool. After selecting 7 seed guidelines, the committee prepared evidence summaries to generate data exaction tables. These summaries comprised the 4 main themes of this version of the guidelines: colonoscopy; a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; probiotics; and rifaximin. To adopt the core recommendations of the guidelines, the Delphi technique (ie, a panel of experts on IBS) was used. To enhance dissemination of the clinical practice guidelines, a Korean version will be made available, and a food calendar for patients with IBS is produced.
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Affiliation(s)
- Kyung Ho Song
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon,
Korea
- Konyang University Myunggok Medical Research Institute Daejeon,
Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul,
Korea
- Correspondence: Hye-Kyung Jung, MD, PhD Department of Internal Medicine, Ewha Womans University Medical Center, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea, Tel: +82-2-2650-2874, Fax: +82-2-2655-2874, E-mail:
| | - Hyun Jin Kim
- Department of Internal Medicine, Gyeongsang National University, College of Medicine, Jinju,
Korea
| | - Hoon Sup Koo
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon,
Korea
| | - Yong Hwan Kwon
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu,
Korea
| | - Hyun Duk Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan,
Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin,
Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan,
Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan,
Korea
| | - Dae Hyeon Cho
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul,
Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul,
Korea
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32
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Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018; 154:1140-1171.e1. [PMID: 29274869 DOI: 10.1053/j.gastro.2017.11.279] [Citation(s) in RCA: 226] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Central neuromodulators (antidepressants, antipsychotics, and other central nervous system-targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut-brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations. METHODS The working team summarized the literature on the pharmacology of central neuromodulators and their effects on gastrointestinal sensorimotor function and conducted an evidence-based review on their use for treating FGID syndromes. Because of the paucity of data for FGIDs, we included data for non-gastrointestinal painful disorders and specific symptoms of pain, nausea, and vomiting. This information was combined into a final document comprising a synthesis of available evidence and recommendations for clinical use guided by the research and clinical experience of the experts on the committee. RESULTS The evidence-based review on neuromodulators in FGID, restricted by the limited available controlled trials, was integrated with open-label studies and case series, along with the experience of experts to create recommendations using a consensus (Delphi) approach. Due to the diversity of conditions and complexity of treatment options, specific recommendations were generated for different FGIDs. However, some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship. CONCLUSIONS Based on systematic and selectively focused review and the consensus of a multidisciplinary panel, we have provided summary information and guidelines for the use of central neuromodulators in the treatment of chronic gastrointestinal symptoms and FGIDs. Further studies are needed to confirm and refine these recommendations.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, North Carolina.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans Törnblom
- Departments of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Abstract
PURPOSE OF REVIEW The purpose of this review is to examine the evidence supporting the use of recently developed pharmacological treatments for IBS together with new evidence supporting more traditional therapies in order to understand where the new agents are best used in the treatment pathway. RECENT FINDINGS There is evidence to support the use of traditional treatments such as antispasmodics, antidepressants and dietary alteration in IBS. New therapeutic agents such as Linaclotide, Lubiprostone, Plecanatide, Rifaxamin and Eluxadoline are all more effective than placebo in treating symptoms of IBS with Tenapanor being a promising new agent. The majority of patients, however, treated with these medications remain symptomatic and they are not suitable for use in all patients. SUMMARY Traditional treatments such as antispasmodics, antidepressants, dietary and lifestyle modifications retain their importance in the treatment of IBS with the newer agents to be considered wherever these treatments are ineffective or poorly tolerated.
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Camilleri M, Ford AC. Pharmacotherapy for Irritable Bowel Syndrome. J Clin Med 2017; 6:E101. [PMID: 29077050 PMCID: PMC5704118 DOI: 10.3390/jcm6110101] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 12/11/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a disorder of the brain-gut axis; the pathophysiological mechanisms include altered colonic motility, bile acid metabolism, neurohormonal regulation, immune dysfunction, alterations in the epithelial barrier and secretory properties of the gut. This article reviews the mechanisms, efficacy, and safety of current pharmacotherapy, and medications that are in phase III trials for the treatment of IBS. There remains a significant unmet need for effective treatments-particularly for the pain component of IBS-although the introduction of drugs directed at secretion, motility and a non-absorbable antibiotic provide options for the bowel dysfunction in IBS.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) and Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA.
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds and Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, Leeds LS9 7TF, UK.
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Coates MD, Tekin I, Vrana KE, Mawe GM. Review article: the many potential roles of intestinal serotonin (5-hydroxytryptamine, 5-HT) signalling in inflammatory bowel disease. Aliment Pharmacol Ther 2017; 46:569-580. [PMID: 28737264 DOI: 10.1111/apt.14226] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 04/10/2017] [Accepted: 06/24/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Serotonin (5-hydroxytryptamine, 5-HT) is an important mediator of every major gut-related function. Recent investigations also suggest that 5-HT can influence the development and severity of inflammation within the gut, particularly in the setting of inflammatory bowel disease (IBD). AIM To review the roles that the intestinal serotonin signalling system plays in gut function, with a specific focus on IBD. METHODS We reviewed manuscripts from 1952 to 2017 that investigated and discussed roles for 5-HT signalling in gastrointestinal function and IBD, as well as the influence of inflammation on 5-HT signalling elements within the gut. RESULTS Inflammation appears to affect every major element of intestinal 5-HT signalling, including 5-HT synthesis, release, receptor expression and reuptake capacity. Importantly, many studies (most utilising animal models) also demonstrate that modulation of selective serotonergic receptors (via agonism of 5-HT4 R and antagonism of 5-HT3 R) or 5-HT signal termination (via serotonin reuptake inhibitors) can alter the likelihood and severity of intestinal inflammation and/or its complicating symptoms. However, there are few human studies that have studied these relationships in a targeted manner. CONCLUSIONS Insights discussed in this review have strong potential to lead to new diagnostic and therapeutic tools to improve the management of IBD and other related disorders. Specifically, strategies that focus on modifying the activity of selective serotonin receptors and reuptake transporters in the gut could be effective for controlling disease activity and/or its associated symptoms. Further studies in humans are required, however, to more completely understand the pathophysiological mechanisms underlying the roles of 5-HT in this setting.
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Affiliation(s)
- M D Coates
- Department of Medicine, Division of Gastroenterology & Hepatology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - I Tekin
- Neuroscience Institute, University of California at Santa Barbara, Santa Barbara, CA, USA
| | - K E Vrana
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | - G M Mawe
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, VT, USA
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Kułak-Bejda A, Bejda G, Waszkiewicz N. Antidepressants for irritable bowel syndrome-A systematic review. Pharmacol Rep 2017; 69:1366-1379. [PMID: 29132094 DOI: 10.1016/j.pharep.2017.05.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/21/2017] [Accepted: 05/26/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND According to the multifactorial etiology of Irritable bowel syndrome (IBS), psychological factors play an important role. It is possible that antidepressant therapy may be more effective for patients with IBS. The aim of this study was a systematic review of the best available antidepressant therapies for IBS. METHODS The databases Medline, PubMed, EMBASE, and the Cochrane Controlled Trials Register for randomized controlled trials were searched for studies published before September 2016. Meta-analyses, randomized controlled trials, controlled trials, uncontrolled trials, cohort studies, and open-label studies were analyzed. RESULTS Of 513 articles, 29 fulfilled the inclusion criteria: 6 meta-analyses, 18 randomized controlled trials, and 5 studies without randomization. In these studies, the efficacy of tricyclics, selective serotonin reuptake inhibitors or serotonin-noradrenaline reuptake inhibitors, were analyzed in IBS. Different interventions were used, though in most studies their effect on global symptom relief in IBS as a primary outcome was investigated. Generally, patients' tolerance of the therapies was good. Only severe adverse events were observed as a result of the nature of the drug. CONCLUSIONS Generally, antidepressants improved IBS symptoms. In comparison with placebo, tricyclic therapy for IBS was more effective than selective serotonin reuptake inhibitors. Antidepressants might be an alternative therapy for patients suffering from IBS, especially diarrhea-predominant IBS.
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Affiliation(s)
| | - Grzegorz Bejda
- Medical University of Białystok, Department of Integrated Medical Care, Białystok, Poland
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Ford AC, Luthra P, Tack J, Boeckxstaens GE, Moayyedi P, Talley NJ. Efficacy of psychotropic drugs in functional dyspepsia: systematic review and meta-analysis. Gut 2017; 66:411-420. [PMID: 26567029 DOI: 10.1136/gutjnl-2015-310721] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/13/2015] [Accepted: 10/24/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Functional dyspepsia (FD) is a chronic gastroduodenal disorder. Individuals with FD demonstrate visceral hypersensitivity, abnormal central pain processing, and low mood, but it is unclear whether psychotropic drugs are an effective treatment for the condition. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs). DESIGN MEDLINE, EMBASE, EMBASE Classic, PsychINFO and the Cochrane Controlled Trials Register were searched (up to June 2015) for RCTs recruiting adults with FD comparing psychotropic drugs with placebo. We contacted authors directly to maximise trial eligibility and minimise risk of bias for studies. Dichotomous symptom data were pooled to obtain relative risk (RR) of remaining symptomatic after therapy, with 95% CIs. RESULTS The search identified 2795 citations; 13 RCTs (1241 patients) were eligible. Ten trials were at low risk of bias. The RR of FD symptoms not improving with psychotropic drugs versus placebo was 0.78 (95% CI 0.68 to 0.91) (number needed to treat=6; 95% CI 4 to 16). However, benefit was limited to antipsychotics and tricyclic antidepressants. When only studies that excluded individuals with coexistent mood disorder were considered, there was no benefit. Total numbers of adverse events and adverse events leading to withdrawal were significantly more common, with a number needed to harm of 21 for both. CONCLUSIONS Psychotropic drugs may be an effective treatment for FD, but the effect appears to be limited to antipsychotics and tricyclic antidepressants with fewer trials for other agents, meaning that firm conclusions for efficacy cannot be made. More data from high quality RCTs are required to support their use in the treatment of FD.
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Affiliation(s)
- Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Pavit Luthra
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University Leuven, Leuven, Belgium
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University Leuven, Leuven, Belgium
| | - Paul Moayyedi
- Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, Ontario, Canada
| | - Nicholas J Talley
- Faculty of Health, University of Newcastle, Callaghan, New South Wales, Australia
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Camilleri M, Ford AC. Irritable Bowel Syndrome: Pathophysiology and Current Therapeutic Approaches. Handb Exp Pharmacol 2017; 239:75-113. [PMID: 27995391 DOI: 10.1007/164_2016_102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Irritable bowel syndrome (IBS) is a prevalent condition affecting 10-20% of adults in most countries; IBS results in significant morbidity and health care costs. IBS is a disorder of the brain-gut axis, and recent insights into the pathophysiological mechanisms include altered bile acid metabolism, neurohormonal regulation, immune dysfunction, alterations in the epithelial barrier, and secretory properties of the gut. There remains a significant unmet need for effective treatments, particularly for the pain component of IBS, although the introduction of drugs directed at secretion, motility, and a nonabsorbable antibiotic provides an option for the bowel dysfunction in IBS.
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Affiliation(s)
- Michael Camilleri
- Department of Medicine, Pharmacology, and Physiology, Division of Gastroenterology, Mayo Clinic College of Medicine, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), 200 First Street S.W, Rochester, MN, 55905, USA.
| | - Alexander C Ford
- Department of Gastroenterology and Honorary Consultant Gastroenterologist, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds and Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, Leeds, UK
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39
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Park CH, Han DS. Pharmacotherapy of irritable bowel syndrome. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2017. [DOI: 10.5124/jkma.2017.60.1.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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Abstract
Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.
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Abstract
Constipation is common in the general population and for those on opioids and/or who are suffering from advanced cancer. Self-management consists of dietary changes, exercise, and laxatives. However, responses to self-management efforts are often inadequate to relieve the subjective and objective experience of constipation. Multiple new anti-constipating medications have recently been tested in randomized trials and the following are available commercially: probiotics, prucalopride, lubiprostone, linaclotide, elobixibat, antidepressants, methylnaltrexone, alvimopan, and naloxegol. This review will discuss the evidence-based benefits of these medications and outline an approach to managing constipation.
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Affiliation(s)
- Mellar Davis
- Cleveland Clinic Lerner School of Medicine Case, Western Reserve University, 9500 Euclid Avenue, T34, Cleveland, OH, 44195, USA.
- Clinical Fellowship Program, Cleveland, OH, USA.
- Palliative Medicine and Supportive Oncology Services, Taussig Cancer Institute, Cleveland, OH, USA.
| | - Pamela Gamier
- Cleveland Clinic Lerner School of Medicine Case, Western Reserve University, 9500 Euclid Avenue, T34, Cleveland, OH, 44195, USA
- Clinical Fellowship Program, Cleveland, OH, USA
- Palliative Medicine and Supportive Oncology Services, Taussig Cancer Institute, Cleveland, OH, USA
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Abstract
BACKGROUND The use of psychotropic medications, particularly antidepressants, is common in patients with inflammatory bowel disease (IBD) in spite of a lack of their robust efficacy in this population. This review provides an overview of the use trends of different classes of antidepressant and anti-anxiety medication and their effects on mood, nervous system function, gastrointestinal physiology and immunity drawing from the literature available in the general population, other medical conditions, and when available, patients with IBD. It also covers the evidence base for the actions, efficacy, and potential complications of antidepressants organized by different classes. METHODS We conducted a PubMed search of articles relating the different drug classes probed to the terms above in different populations of interest. All types of articles were accepted including case reports and series, open and randomized trials, reviews, and expert opinion. We also examined the reference lists of the publications found. RESULTS Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the most commonly prescribed agents for anxiety and depression in patients with IBD, though their efficacy for these conditions in the general population are mild to moderate at best. SSRIs are generally well tolerated, though at higher doses, they, like most antidepressant classes, can be associated with activation, serotonergic syndrome, and increased suicidal ideation. TCAs have many more serious side effects but have some shown efficacy for functional GI symptoms. A newer class, the serotonin noradrenergic reuptake inhibitors (SNRIs), can be effective for refractory depression, anxiety and chronic pain syndromes with a side effect profile similar to both SSRIs and more mild manifestations of TCAs. Mirtazapine has moderate efficacy for depression if sedation and weight gain side effects are tolerated and some small support for use in nausea and vomiting. Bupropion targets dopamine and noradrenaline reuptake and has moderate efficacy for depression, and some small support for use in fatigue and smoking cessation. Buspirone has an indication for generalized anxiety disorder though studies show only a minimal benefit. It has some growing evidence for use in functional dyspepsia. Most of these agents have physiological effects on the brain, immune system, and gastrointestinal tract (with the exception of bupropion) hence their therapeutic and side effects manifested in these systems. CONCLUSION Antidepressant medications are frequently prescribed for depression, anxiety disorders, and chronic pain syndromes, but overall support for their efficacy is modest at best. Psychological interventions have growing support for having much more robust effects without the side effects of antidepressants and should be considered first-line treatment or at least an adjunct to psychotropic medications for these conditions.
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Imipramine for Treatment of Esophageal Hypersensitivity and Functional Heartburn: A Randomized Placebo-Controlled Trial. Am J Gastroenterol 2016; 111:217-24. [PMID: 26753892 DOI: 10.1038/ajg.2015.413] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Tricyclic antidepressants could be effective in the treatment of symptoms related to hypersensitive esophagus through their pain-modulating effect. We therefore assessed the benefit of imipramine in patients with esophageal hypersensitivity and functional heartburn. METHODS Patients with normal endoscopy findings and typical reflux symptoms despite standard-dose proton-pump inhibitor therapy underwent 24-h pH-impedance monitoring. Patients with established esophageal hypersensitivity or functional heartburn were randomly assigned to receive 8 weeks of either once-daily imipramine 25 mg (n=43) or placebo (n=40). The primary end point was satisfactory relief of reflux symptoms, defined as a >50% reduction in the gastroesophageal reflux disease score. The secondary end point was improvement in quality-of-life (QoL) as assessed by the 36-Item Short Form Health Survey score. RESULTS Patients receiving imipramine did not achieve a higher rate of satisfactory relief of reflux symptoms than did patients receiving placebo (intention-to-treat (ITT) analysis: 37.2 vs. 37.5%, respectively; odds ratio (OR), 0.99; 95% confidence interval (CI), 0.41-2.41; per-protocol (PP) analysis: 45.5 vs. 41.2%, respectively; OR, 1.19; 95% CI, 0.45-3.13). Subgroup analysis to assess the efficacy of imipramine for either esophageal hypersensitivity or functional heartburn yielded similar results. Treatment with imipramine provided significant improvement of QoL by PP analysis (72±17 and 61±19, respectively; P=0.048), but ITT analysis did not reveal any differences between imipramine and placebo (68±19 and 61±19, respectively; P=0.26). Adverse events were similar in both groups; however, constipation was more common with imipramine than placebo (51.2 vs. 22.5%, respectively; P=0.01). CONCLUSIONS Although low-dose imipramine shows potential QoL benefits, it does not relieve symptoms more effectively than does placebo in patients with either esophageal hypersensitivity or functional heartburn.
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Abstract
OPINION STATEMENT Irritable bowel syndrome (IBS) is a common gastrointestinal disease characterized by abdominal pain and change in bowel habits. IBS diarrhea predominant (IBS-D), which is arguably the most common subset of IBS, is also associated with rectal urgency, increased frequency, abdominal bloating, and loose to watery stools. Current treatments for diarrhea include mu-opioid agonists (i.e., loperamide, lomotil) and bile acid sequestrants (i.e., cholestyramine) while treatments for abdominal pain include antispasmodics (i.e., hyoscyamine, dicyclomine) and tricyclic antidepressants (i.e., amitriptyline). There are currently 3 FDA-approved treatments for IBS-D, which have been shown to improve both abdominal pain and diarrhea. Alosetron was initially approved by FDA 2000; however, its use is now limited to women with severe IBS-D symptoms refractory to other treatment. Eluxadoline, a mixed mu-opioid agonist, and rifaximin, a broad spectrum gut specific antibiotic, were both FDA approved in 2015. Eluxadoline has been shown to relieve abdominal pain and stool consistency in appropriate candidates. While large trials already showed the efficacy of rifaximin in treating non-constipated IBS for bloating, stool consistency, and abdominal pain, the recent TARGET 3 trial demonstrates that retreatment is also effective. While these new treatments significantly expand options for patients suffering from IBS-D, there is likely to remain a need for additional safe and effective therapies.
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Talley NJ, Locke GR, Saito YA, Almazar AE, Bouras EP, Howden CW, Lacy BE, DiBaise JK, Prather CM, Abraham BP, El-Serag HB, Moayyedi P, Herrick LM, Szarka LA, Camilleri M, Hamilton FA, Schleck CD, Tilkes KE, Zinsmeister AR. Effect of Amitriptyline and Escitalopram on Functional Dyspepsia: A Multicenter, Randomized Controlled Study. Gastroenterology 2015; 149:340-9.e2. [PMID: 25921377 PMCID: PMC4516571 DOI: 10.1053/j.gastro.2015.04.020] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 03/13/2015] [Accepted: 04/16/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Antidepressants are frequently prescribed to treat functional dyspepsia (FD), a common disorder characterized by upper abdominal symptoms, including discomfort or postprandial fullness. However, there is little evidence of the efficacy of these drugs in patients with FD. We performed a randomized, double-blind, placebo-controlled trial to evaluate the effects of antidepressant therapy on symptoms, gastric emptying (GE), and meal-induced satiety in patients with FD. METHODS We performed a study at 8 North American sites of patients who met the Rome II criteria for FD and did not have depression or use antidepressants. Patients (n = 292; 44 ± 15 years old, 75% were female, 70% with dysmotility-like FD, and 30% with ulcer-like FD) were randomly assigned to groups given placebo, 50 mg amitriptyline, or 10 mg escitalopram for 10 weeks. The primary end point was adequate relief of FD symptoms for ≥5 weeks of the last 10 weeks (of 12). Secondary end points included GE time, maximum tolerated volume in Nutrient Drink Test, and FD-related quality of life. RESULTS An adequate relief response was reported by 39 subjects given placebo (40%), 51 given amitriptyline (53%), and 37 given escitalopram (38%) (P = .05, after treatment, adjusted for baseline balancing factors including all subjects). Subjects with ulcer-like FD given amitriptyline were >3-fold more likely to report adequate relief than those given placebo (odds ratio = 3.1; 95% confidence interval: 1.1-9.0). Neither amitriptyline nor escitalopram appeared to affect GE or meal-induced satiety after the 10-week period in any group. Subjects with delayed GE were less likely to report adequate relief than subjects with normal GE (odds ratio = 0.4; 95% confidence interval: 0.2-0.8). Both antidepressants improved overall quality of life. CONCLUSIONS Amitriptyline, but not escitalopram, appears to benefit some patients with FD, particularly those with ulcer-like (painful) FD. Patients with delayed GE do not respond to these drugs. ClinicalTrials.gov ID: NCT00248651.
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Affiliation(s)
- Nicholas J. Talley
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN,Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | | | - Yuri A. Saito
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ann E. Almazar
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Brian E. Lacy
- Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John K. DiBaise
- Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ
| | | | - Bincy P. Abraham
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
| | - Hashem B. El-Serag
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
| | - Paul Moayyedi
- Gastroenterology, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | - Cathy D. Schleck
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Törnblom H, Drossman DA. Centrally targeted pharmacotherapy for chronic abdominal pain. Neurogastroenterol Motil 2015; 27:455-67. [PMID: 25651186 DOI: 10.1111/nmo.12509] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic abdominal pain in the context of the functional gastrointestinal disorders departs from a more traditional approach to treating gastrointestinal symptoms. Chronic abdominal pain involves a dysregulation of brain-gut modulation of afferent signaling, so treatments directed toward the gut are not usually sufficient to achieve a clinical response. Rather the methods of treatment depend on re-establishing central pain regulation. PURPOSE A conceptual model of predisposing, precipitating, and perpetuating factors is used to explain how a situation of chronic pain develops and it provides the evidence for central neuron degeneration as relevant to this chain of events. The rationale for centrally targeted medications, in particular antidepressants, is discussed with regard to effects independent of their role in treating psychiatric disorders: with regard to downregulation of afferent pain signals and their potential role in neuron proliferation. Finally, guiding examples of which drug to use and treatment combinations involving multiple drugs, augmentation treatment, are outlined and some brief clinical cases of centrally targeted pharmacotherapy.
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Affiliation(s)
- H Törnblom
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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47
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Abstract
Drug-induced gastrointestinal disorders can mimic conditions, such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) and, hence, recognition can prevent unnecessary investigations and treatment. While the knowledge and awareness relating to the adverse gastrointestinal effects of some medications, such as non-steroidal anti-inflammatory drugs are well established, other commonly prescribed drugs, such as antipsychotics, antidepressants and metformin are less well understood and warrant further study. This review attempts to integrate recent information regarding adverse drug reactions and place this in a useful clinical context.
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Affiliation(s)
- H L Philpott
- Department of Gastroenterology, Monash University, Eastern Health, Melbourne, Victoria, Australia Box Hill Hospital, Melbourne, Australia The Alfred Hospital, Melbourne, Australia
| | - S Nandurkar
- Department of Gastroenterology, Monash University, Eastern Health, Melbourne, Victoria, Australia Box Hill Hospital, Melbourne, Australia
| | - J Lubel
- Department of Gastroenterology, Monash University, Eastern Health, Melbourne, Victoria, Australia Box Hill Hospital, Melbourne, Australia
| | - P R Gibson
- Department of Gastroenterology, Monash University, Eastern Health, Melbourne, Victoria, Australia Box Hill Hospital, Melbourne, Australia The Alfred Hospital, Melbourne, Australia
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Yee R, Manoharan S, Hall C, Hayashi A. Optimizing bowel preparation for colonoscopy: what are the predictors of an inadequate preparation? Am J Surg 2015; 209:787-92; discussion 792. [PMID: 25796095 DOI: 10.1016/j.amjsurg.2014.12.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/23/2014] [Accepted: 12/30/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND This retrospective study evaluates factors that are associated with an inadequate bowel preparation. METHODS A chart review was performed on 2,101 patients who underwent colonoscopy. The quality of preparation was classified as adequate or inadequate. Univariate and multivariate regression analyses identified factors associated with inadequate preparations. RESULTS A total of 91.5% of preparations were adequate. Standard preparations using polyethylene glycol-electrolyte solution and sodium picosulfate alone were 91.1% adequate. Regimens with adjuncts were 91.9% adequate. Factors that predicted an inadequate preparation include the following: stroke/dementia (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.6 to 7.7, P = .002), opioids (OR 2.3, 95% CI 1.1 to 4.6, P = .02), male sex (OR 2.0, 95% CI 1.4 to 2.9, P = .000), calcium channel blockers (OR 1.9, 95% CI 1.1 to 3.3, P = .03), and antidepressants (OR 1.7, 95% CI 1.1 to 2.7, P = .02). CONCLUSIONS Several factors are associated with inadequate preparations. Adjuncts do not improve preparation quality. The effect of patient education on preparation quality is an area for further research.
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Affiliation(s)
- Ruby Yee
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Shiana Manoharan
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christine Hall
- Department of Emergency Medicine, Victoria General Hospital, Victoria, BC, Canada
| | - Allen Hayashi
- Department of Surgery, Victoria General Hospital, Victoria, BC, Canada
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Weijenborg PW, de Schepper HS, Smout AJPM, Bredenoord AJ. Effects of antidepressants in patients with functional esophageal disorders or gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol 2015; 13:251-259.e1. [PMID: 24997325 DOI: 10.1016/j.cgh.2014.06.025] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 06/01/2014] [Accepted: 06/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with functional esophageal disorders present with symptoms of chest pain, heartburn, dysphagia, or globus in the absence of any structural abnormality. Visceral hypersensitivity is a feature of these functional disorders, and might be modulated by antidepressant therapy. We evaluated evidence for the efficacy of antidepressant therapy for symptoms associated with esophageal visceral hypersensitivity in patients with functional esophageal disorders or gastroesophageal reflux disease (GERD). METHODS We performed a systematic search of the Cochrane Comprehensive Trial Register, MEDLINE, and EMBASE (through February 2014). We analyzed relevant randomized, placebo-controlled trials reporting the effect of antidepressant therapy on experimentally induced esophageal sensation or intensity, or frequency of heartburn, chest pain, dysphagia, or globus. RESULTS The search strategy identified 378 articles; 15 described randomized controlled trials that were eligible for inclusion. In addition, 1 conference abstract and 2 case reports were included, providing the best available evidence on specific symptoms. Esophageal pain thresholds increased by 7% to 37% after antidepressant therapy. Antidepressant therapy reduced functional chest pain over a range from 18% to 67% and reduced heartburn in patients with GERD over a range of 23% to 61%. One study included patients with globus and none of the studies included patients with functional heartburn or functional dysphagia. CONCLUSIONS Based on a systematic review, antidepressants modulate esophageal sensation and reduce functional chest pain. There is limited evidence that antidepressants benefit a subgroup of patients with GERD. More controlled trials are needed to investigate the effects of antidepressants on functional esophageal disorders.
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Affiliation(s)
- Pim W Weijenborg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Heiko S de Schepper
- Department of Gastroenterology and Hepatology, Universitair Ziekenhuis Antwerpen, Antwerpen, Belgium
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Xie C, Tang Y, Wang Y, Yu T, Wang Y, Jiang L, Lin L. Efficacy and Safety of Antidepressants for the Treatment of Irritable Bowel Syndrome: A Meta-Analysis. PLoS One 2015; 10:e0127815. [PMID: 26252008 PMCID: PMC4529302 DOI: 10.1371/journal.pone.0127815] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 04/18/2015] [Indexed: 12/15/2022] Open
Abstract
AIM The aim of this meta-analysis was to analyze the efficacy and safety of antidepressants for the treatment of irritable bowel syndrome. METHODS We searched MEDLINE, EMBASE, Scopus and The Cochrane Library for randomized controlled trials investigating the efficacy and safety of antidepressants in the treatment of irritable bowel syndrome. Article quality was evaluated by Jadad score. RevMan 5.0 and Stata 12.0 were used for the meta-analysis. RESULTS Twelve randomized controlled trials were included in this study and most of these trials were of high quality (Jadad score ≥4). Five articles focused on tricyclic antidepressants, six articles involved selective serotonin reuptake inhibitors, and one article investigated both types of treatment. The pooled risk ratio showed antidepressant treatment can improve global symptoms (RR = 1.38, 95% CI 1.08, 1.77). In the subgroup analysis, treatment with tricyclic antidepressants showed an improvement in global symptoms (RR = 1.36, 95% CI 1.07, 1.71), while treatment with selective serotonin reuptake inhibitors showed no statistically significant difference in global symptoms compared with the control groups (RR = 1.38, 95% CI 0.83, 2.28). The pooled risk ratio of dropout due to side effects following antidepressant treatment was 1.71 with 95% CI (0.98, 2.99). The subgroup analysis showed the pooled risk ratio of dropout in the tricyclic antidepressants group was 1.92 with 95% CI (0.89, 4.17). In the selective serotonin reuptake inhibitors group, the pooled risk ratio of dropout was 1.5 with 95% CI (0.67, 3.37). Selective serotonin reuptake inhibitors showed no benefit in alleviating abdominal pain and improving quality of life. There was no difference in the incidence of common adverse events between treatment and control groups. CONCLUSIONS TCAs can improve global symptoms of irritable bowel syndrome, while there was no strong evidence to confirm the effectiveness of SSRIs for the treatment of IBS.
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Affiliation(s)
- Chen Xie
- Department of Gastroenterology, the First Affiliated Hospital Nanjing Medical University, Nanjing, China
| | - Yurong Tang
- Department of Gastroenterology, the First Affiliated Hospital Nanjing Medical University, Nanjing, China
| | - Yunfeng Wang
- Library of Nanjing Medical University, Nanjing, China
| | - Ting Yu
- Department of Gastroenterology, the First Affiliated Hospital Nanjing Medical University, Nanjing, China
| | - Yun Wang
- Department of Gastroenterology, the First Affiliated Hospital Nanjing Medical University, Nanjing, China
| | - Liuqin Jiang
- Department of Gastroenterology, the First Affiliated Hospital Nanjing Medical University, Nanjing, China
| | - Lin Lin
- Department of Gastroenterology, the First Affiliated Hospital Nanjing Medical University, Nanjing, China
- * E-mail:
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