Non-pharmacological treatments for irritable bowel syndrome: study protocol of an umbrella review of systematic review and meta-analyses

Efficacy of different courses of acupuncture for diarrhea irritable bowel syndrome: A protocol for systematic review and meta-analysis

Irritable Bowel Syndrome (IBS) is the most common functional gastrointestinal disorder. As one of the most common subtypes of IBS, IBS-D can impair the patients' quality of life (QOL) and decreased work productivity. Acupuncture may be a potential treatment for patients with IBS-D. However, the treatment course of acupuncture was diverse. It is unclear what is the optimal acupuncture treatment courses for acupuncture. The efficacy and safety of different courses of acupuncture for IBS-D have not been systematically evaluated yet. The purpose of this study is to evaluate effectiveness of Acupuncture of different courses in the treatment of IBS-D and provide sufficient evidence for clinical recommendations for IBS-D. We will follow the Preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) guidelines to design the protocol of a systematic review and meta-analysis. This systematic review is registered in PROSPERO (CRD42023418846). We will include randomized controlled trials (RCTs) in which the efficacy of Acupuncture is compared with a placebo, sham acupuncture or Pinaverium bromide in the treatment of IBS-D with no language restrictions. The outcomes of interest will be efficiency rate and the Symptoms Severity Score. RCTs will be searched in the electronic database and Clinical Trials Registry Platform from inception to April 2023. Two independent reviewers will independently select studies, extract data from the included studies, and assess the risk of bias using the Cochrane tool. We will choose a random or fixed-effects model based on the heterogeneity index. We will use the relative risk and mean difference to estimate data with 95% CI. A stratified meta-analysis was conducted to evaluate the effect of different treatment courses of Acupuncture: 2weeks, 4weeks(or 1 months), 6 weeks, and 8 weeks. If there is significant clinical and methodological heterogeneity, we will look for the reason for heterogeneity and perform a subgroup analysis. According to the Grading of Recommendations Assessment, Development and Evaluation (GRADE), we will evaluate the evidence quality and provide the recommendation's strength.

Atractylodes macrocephala-Paeonia lactiflora Class Formula for the Treatment of Irritable Bowel Syndrome: A Systematic Review With Meta-Analysis and Trial Sequential Analysis

Previous meta-analyses suggested that Chinese herbal medicine (CHM) is effective for irritable bowel syndrome (IBS). Formulas with Atractylodes macrocephala and Paeonia lactiflora as the core pairs have been widely used by traditional Chinese medicine (TCM) practitioners for the treatment of IBS. We aimed to examine the efficacy and safety of the Atractylodes macrocephala-Paeonia lactiflora class formula (A-P CHM) for IBS through a meta-analysis and trial-sequential analysis (TSA). The protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023439087. We searched seven databases for data up to May 23, 2023. The primary outcome was global IBS symptom relief. The secondary outcomes included the IBS severity scoring system (IBS-SSS) score and treatment-related adverse events. The relative ratio (RR) (dichotomous variables), the standardized mean difference (SMD) (continuous variables), the number needed to treat (NNT), the number needed to harm (NNH), and the required information size (RIS) were calculated. Twenty-four eligible articles with 3,768 participants were included. Thirteen trials were at low risk of bias (RoB). Compared with placebo or Western medication, A-P CHM was associated with a significantly higher proportion of relief of global IBS symptoms. The TSA analysis verified the primary outcome. For the secondary outcome, the A-P CHM IBS-SSS score was lower than Western medication or placebo at the end of the treatment, which was further confirmed by the TSA analysis. We asserted that A-P CHM might be a potential candidate for patients with IBS, especially for IBS-D. It may provide a theoretical basis for future optimization of irritable bowel syndrome with diarrhea (IBS-D) herbal formulas. The overall certainty of the evidence was not high; more tightly designed randomized controlled trials (RCTs) are required in the future.

Exploring the synergistic pharmacological mechanism of Huoxiang Drink against irritable bowel syndrome by integrated data mining and network pharmacology

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder, characterized by abdominal pain, bloating, and changes in bowel habits. Huoxiang Drink (HD), derived from traditional Chinese medicine, has been reported to effectively treat digestive disorders caused by external cold and internal dampness. However, the pharmaceutical targets and mechanisms for HD against IBS remain unclear. Data mining, bioinformatics analysis, and network pharmacology were employed to explore the potential pharmacological mechanisms of HD against IBS. In this study, we screened 50 core targets to investigate the pharmacological mechanisms of HD against IBS. Enrichment analysis revealed that HD may participate in various signaling pathways, especially the inflammation-related tumor necrosis factor, signaling pathway and hypoxia-inducible factor signaling pathway. Molecular docking results confirmed that MOL000098 (Quercetin), MOL000006 (Luteolin), MOL005828 (Nobiletin), MOL005916 (Irisolidone), and MOL004328 (Naringenin), as key active ingredients in HD, bound to core targets (tumor protein P53, tumor necrosis factor, matrix metalloproteinases 9, and vascular endothelial growth factor-A) for topical treatment of IBS. This study suggested that HD offered a potential therapeutic strategy against IBS. Our findings may facilitate the efficient screening of active ingredients in HD and provide a theoretical basis for further validating the clinical therapeutic effects of HD on treating IBS.

Chinese herbal medicine versus antispasmodics in the treatment of irritable bowel syndrome: A network meta-analysis

BACKGROUND

Chinese herbal medicine (CHM) is gaining popularity in treating irritable bowel syndrome (IBS). Although its efficacy was shown in recent randomized controlled trials (RCTs), it is rarely compared with antispasmodics to confirm its effectiveness. We aimed to resolve this uncertainty through a network meta-analysis.

METHODS

We searched for RCTs that compared CHM or antispasmodics with placebo or one of them in the treatment of IBS. The primary outcomes were adequate relief of global IBS symptoms and abdominal pain. The data were pooled using a random-effects model. The effect size measure was pooled relative risk (RR), and treatments were ranked according to their P-scores.

KEY RESULTS

We included 57 RCTs (n = 8869). After completion of treatment, drotaverine, individual CHM, otilonium, cimetropium, standard CHM, and pinaverium were efficacious in adequate relief of global IBS symptoms, and drotaverine ranked the first (RR, 2.33 [95% CI, 1.31-4.14], P-score =0.91); no difference was found between these treatments. After completion of treatment, drotaverine, standard CHM, pinaverium, and individual CHM were efficacious in abdominal pain, and drotaverine ranked the first (RR, 2.71 [95% CI, 1.69-4.36], P-score =0.91); no difference was found between these treatments. Standard CHM had significantly more adverse events than placebo (RR, 1.82 [95% CI, 1.12-2.94]) and other treatments.

CONCLUSIONS

CHM and antispasmodics were efficacious for improvement of global IBS symptoms and abdominal pain. The adverse events of CHM were higher than antispasmodics; however, the heterogeneity of CHM formulas and the very low quality of the evidence warrants further investigation.

Chinese Herbal Medicine for Irritable Bowel Syndrome: A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

Purpose: Chinese herbal medicine (CHM) is an important complementary and alternative therapy for the management of irritable bowel syndrome (IBS). Previous meta-analyses suggested that CHM is effective for IBS; nonetheless, its effectiveness is inconclusive owing to repeated significance testing. We aimed to examine the efficacy and safety of CHM for IBS through a meta-analysis and trial sequential analysis (TSA).

Methods: We searched OVID Medline, Embase, Cochrane Central Register of Controlled Trials, and Web of Science from January 1, 1980, to September 20, 2020. The primary outcome was adequate relief of global IBS symptoms. The secondary outcomes included relief of abdominal pain and treatment-related adverse events. The relative ratio (RR) and required information size (RIS) were calculated for each outcome.

Results: Ten trials recruiting 2,501 participants were included. Seven (70%) trials were at low risk of bias (RoB). Compared with placebo, CHM was associated with a significantly higher proportion of adequate relief of global IBS symptoms [RR 1.76 (95% confidence interval (95%CI), 1.33–2.33); I² = 81.1%; p < 0.001]. The RIS was 1,083 for the primary outcome, and the accrued information size was 1,716. The analysis of the relief of abdominal pain (three trials with 916 participants) showed similar results compared with placebo [RR 1.85 (95%CI, 1.59–2.14); I² = 0%; p < 0.001; RIS = 197 participants]. CHM was associated with a higher proportion of adverse events compared with placebo [RR 1.51 (95%CI, 1.14–2); I² = 0%; p = 0.004].

Conclusion: CHM was effective in relieving IBS symptoms but caused a higher adverse event rate than placebo. TSA analysis confirmed the findings with sufficient information size.

Management of haemorrhoids: protocol of an umbrella review of systematic reviews and meta-analyses

INTRODUCTION

The prevalence of haemorrhoidal diseases was high in general population, and many treatments are proposed for the management of haemorrhoids. The treatments include conservative and surgical interventions; the credibility and strength of current evidence of their effectiveness are not comprehensively evaluated. We aim to evaluate the credibility of systematic reviews and meta-analyses that assess the effectiveness of the treatments for haemorrhoidal diseases through an umbrella review.

METHODS AND ANALYSIS

We will search Ovid Medline, Embase, Cochrane library and Web of Science from inception to March 2020 without any language restriction. We will include meta-analyses that examine the effectiveness of treatments in the management of haemorrhoids. Two reviewers will independently screen the titles and abstracts of retrieved articles, and they will extract data from the included meta-analyses. For each meta-analysis, we will estimate the effect size of a treatment through the random-effect model and the fixed-effect model, and we will evaluate between-study heterogeneity (Cochrane's Q and I2 statistics) and small-study effect (Egger's test); we will also estimate the evidence of excess significance bias. Evidence of each treatment will be graded according to prespecified criteria. Methodological quality of each meta-analysis will be evaluated by using Assessment of Multiple Systematic Reviews 2. The corrected cover area method will be used to assess the impact of overlap in reviews on the findings of the umbrella review.

ETHICS AND DISSEMINATION

We will present the results of the umbrella review at conferences and publish the final report in a peer-reviewed journal. The umbrella review does not require ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42019140702.

Electroacupuncture Inhibits the Activity of Astrocytes in Spinal Cord in Rats with Visceral Hypersensitivity by Inhibiting P2Y1 Receptor-Mediated MAPK/ERK Signaling Pathway

Background

Irritable bowel syndrome (IBS) is a chronic functional bowel disease characterized by abdominal pain and changes in bowel habits in the absence of organic disease. Electroacupuncture (EA) has been shown to alleviate visceral hypersensitivity (VH) in IBS rat models by inhibiting the activation of astrocytes in the spinal cord. However, the underlying molecular mechanisms mediated by P2Y₁ receptor of this effect of electroacupuncture remain unclear.

Aim

To explore whether EA inhibits the activity of astrocytes in the spinal cord dorsal horn of rat with visceral hypersensitivity by inhibiting P2Y₁ receptor and its downstream mitogen activated protein kinase/extracellular regulated kinase 1 (MAPK/ERK) pathway.

Methods

Ten-day-old Sprague-Dawley (SD) male rats were given an intracolonic injection of 0.2 ml of 0.5% acetic acid (AA) to establish a visceral hypersensitivity model. EA was performed at Zusanli (ST 36) and Shangjuxu (ST 37) at 100 Hz for 1.05 s and 2 Hz for 2.85 s alternately, pulse width for 0.1 ms, 1 mA, 30 min/d, once a day, for 1 week. Cytokines IL-6, IL-1β, and TNF-α were analyzed by ELISA. The expressions of the P2Y₁ receptor and pERK1/2 were analyzed by Western Blot and real-time PCR in the model and EA treated animals to explore the molecular mechanism of EA in inhibiting the activity of spinal cord dorsal horn (L₆-S₂ segment) astrocytes in rats with IBS visceral hypersensitivity.

Results

EA significantly reduced the behavioral abdominal withdrawal reflex score (AWRs) of IBS rats with visceral hypersensitivity induced by AA. For comparison, intrathecal injection of astrocytes activity inhibitor fluorocitrate (FCA) also reduced visceral hypersensitivity in IBS rats. EA at Zusanli and Shangjuxu inhibited the mRNA and protein expression of the glial fibrillary acidic protein (GFAP) and in rat spinal cord and reduced the release of inflammatory cytokines IL-6, IL-1, and TNF-α were analyzed by ELISA. The expressions of the P2Y₁ receptor and pERK1/2 were analyzed by Western Blot and real-time PCR in the model and EA treated animals to explore the molecular mechanism of EA in inhibiting the activity of spinal cord dorsal horn (L₆-S₂ segment) astrocytes in rats with IBS visceral hypersensitivity. β, and TNF-μg, 10 μg, 10 

Conclusion

EA inhibited astrocyte activity in the spinal cord dorsal horn of rat with IBS visceral hypersensitivity by inhibiting the P2Y₁ receptor and its downstream, PKC, and MAPK/ERK1/2 pathways.