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Mazor Y, Malcolm A. Editorial: The unquenchable thirst for drinks and diets as treatments for constipation. Aliment Pharmacol Ther 2024; 59:573-574. [PMID: 38247146 DOI: 10.1111/apt.17814] [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] [Indexed: 01/23/2024]
Abstract
LINKED CONTENTThis article is linked to van der Schoot et al paper. To view this article, visit https://doi.org/10.1111/apt.17782
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Affiliation(s)
- Yoav Mazor
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Allison Malcolm
- University of Sydney, Camperdown, New South Wales, Australia
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Am J Gastroenterol 2023; 118:936-954. [PMID: 37204227 PMCID: PMC10544839 DOI: 10.14309/ajg.0000000000002227] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
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Affiliation(s)
- Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - William D. Chey
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Aamer Imdad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Christopher V. Almario
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan Diem
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Katarina B. Greer
- Cleveland VA Healthcare System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian Hanson
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lucinda A. Harris
- Division of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Cynthia Ko
- Division of Gastroenterology & Hepatology, University of Washington, Washington, DC, USA
| | | | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Eric D. Shah
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- Division of Gastroenterology & Hepatology, Department of Medicine, DartMouth Health, Lebanon, New Hampshire, USA
| | - Anthony J. Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, USA
| | - Shahnaz Sultan
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
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Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Gastroenterology 2023; 164:1086-1106. [PMID: 37211380 PMCID: PMC10542656 DOI: 10.1053/j.gastro.2023.03.214] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
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Affiliation(s)
- Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - William D Chey
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Aamer Imdad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Diem
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Katarina B Greer
- Cleveland VA Healthcare System, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Brian Hanson
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Lucinda A Harris
- Division of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Cynthia Ko
- Division of Gastroenterology & Hepatology, University of Washington, Washington, DC
| | | | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Eric D Shah
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan; Division of Gastroenterology & Hepatology, Department of Medicine, DartMouth Health, Lebanon, New Hampshire
| | - Anthony J Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio
| | - Shahnaz Sultan
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
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A new tool to investigate anorectal disorders in patients with multiple sclerosis: STAR-Q. Prog Urol 2023:S1166-7087(23)00060-X. [PMID: 36906431 DOI: 10.1016/j.purol.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Bowel symptoms are commonly experienced by patients with Multiple sclerosis (PwMS), but no specific questionnaire validated in this population allows a rigorous assessment. OBJECTIVE Validation of a multidimensional questionnaire assessing bowel disorders in PwMS. METHODS A prospective, multicenter study was conducted between April 2020 and April 2021. The STAR-Q (Symptoms' assessmenT of AnoRectal dysfunction Questionnaire), was built in 3 steps. First, literature review and qualitative interviews were performed to create the first version, discussed with a panel of experts. Then, a pilot study assessed comprehension, acceptation and pertinence of items. Finally, the validation study was designed to measure content validity, internal consistency reliability (alpha coefficient of Cronbach) and test-retest reliability [intraclass correlation coefficient (ICC)]. The primary outcome was good psychometric properties with Cronbach's α>0.7 and ICC>0.7. RESULTS We included 231 PwMS. Comprehension, acceptation and pertinence were good. STAR-Q showed a very good internal consistency reliability (Cronbach's α=0.84) and test-retest reliability (ICC=0.89). Final version of STAR-Q was composed of 3 domains corresponding in symptoms (Q1-Q14), treatment and constraints (Q15-Q18) and impact on quality of life (Q19). Three categories of severity were determined (STAR-Q≤16: minor, between 17 and 20: moderate, and≥21: severe). CONCLUSIONS STAR-Q presents very good psychometric properties and allows a multidimensional assessment of bowel disorders in PwMS. LEVEL OF EVIDENCE: 2
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Ohbayashi H, Sato Y, Kiuchi M, Nagazumi A, Kanzo T, Kimura T. Analysis of the impact on efficacy of lubiprostone dose reduction to manage adverse events in the treatment of chronic constipation in Japan. Expert Rev Gastroenterol Hepatol 2022; 16:809-817. [PMID: 35993999 DOI: 10.1080/17474124.2022.2114455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare outcomes between two doses of lubiprostone in patients with chronic constipation (CC), to assess whether dose reduction affects efficacy. METHODS This open-label exploratory study involved 146 patients with CC treated initially with lubiprostone 24 mcg twice daily for a planned duration of 4 weeks. Patients who experienced adverse events (AEs) had their dose reduced to 12 mcg twice daily (for 4 weeks). RESULTS Lubiprostone dose was unchanged in 104 patients and reduced due to AEs in 42 patients. Significant differences in the mean number of bowel movements per week favored the dose-reduced group at Week 1 and end of follow-up. No between-group differences were observed over time for mean number of days per week with bowel movements or mean Bristol Stool Form Scale scores. Symptoms of abdominal bloating, strained defecation, and sensation of incomplete evacuation improved in both groups. Before dose reduction, nausea was reported by 64.3% and diarrhea by 45.2% of patients in the dose-reduced group; after dose reduction, no patients reported nausea and one patient reported diarrhea. CONCLUSION Dose reduction of lubiprostone reduced the incidence of AEs, with no compromise to efficacy, and may be a suitable approach for patients who develop AEs during treatment.
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Affiliation(s)
- Hiroyuki Ohbayashi
- Department of Allergy and Respiratory Medicine, Tohno-Chuo Clinic, Mizunami, Japan
| | - Yasuo Sato
- Department of Gastroenterology, Sato Clinic, Shibuya- ku, Tokyo, Japan
| | - Mari Kiuchi
- Department of Internal Medicine, Kanauchi Medical Clinic, Shinjuku- ku, Tokyo, Japan
| | - Atsushi Nagazumi
- Department of Internal Medicine, Kanauchi Medical Clinic, Shinjuku- ku, Tokyo, Japan
| | | | - Takazumi Kimura
- Department of Gastroenterology, Kimuranaika-ichonaika, Yokohama, Kanagawa, Japan
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Cid-Ruzafa J, Lacy BE, Schultze A, Duong M, Lu Y, Raluy-Callado M, Donaldson R, Weissman D, Gómez-Lumbreras A, Ouchi D, Giner-Soriano M, Morros R, Ukah A, Pohl D. Linaclotide utilization and potential for off-label use and misuse in three European countries. Therap Adv Gastroenterol 2022; 15:17562848221100946. [PMID: 35706826 PMCID: PMC9189524 DOI: 10.1177/17562848221100946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Linaclotide is approved for adults with moderate-to-severe irritable bowel syndrome (IBS) with constipation (IBS-C). Linaclotide is not indicated for weight loss or for patients with inflammatory bowel disease (IBD); it is contraindicated in patients with mechanical bowel obstruction (MBO). Some patients with obesity or eating disorders (ED) may use linaclotide off-label for weight loss or as a laxative. OBJECTIVES To describe the use of linaclotide in clinical practice, including patients with potential for off-label use or misuse. METHODS Post-authorization safety study conducted in three databases from the linaclotide launch date to 2017: the Clinical Practice Research Datalink in the United Kingdom (UK), the Information System for Research in Primary Care database in Spain and the linked Patient, Prescription and Causes of Death Registries in Sweden. Cohorts of patients were identified as having IBS using diagnostic and treatment codes; IBS subtypes were identified using symptoms and treatment codes; patients with obesity, ED, MBO, and IBD were identified using diagnostic codes or body mass index. RESULTS There were 1319, 1981, and 5081 linaclotide users from the United Kingdom, Spain, and Sweden with a median age of 45, 57, and 51 years, respectively; most were females. In the United Kingdom, Spain, and Sweden, respectively: 59.0%, 60.3%, and 31.3% of linaclotide users had an IBS diagnosis recorded, and among those, 68.8%, 61.3%, and 92.7% were classified as IBS-C. The proportions of linaclotide users considered at risk for potential off-label use for weight loss or as a laxative were 17.1%, 29.7%, and 1.7%, and the proportions of users considered at risk of misuse due to a history of MBO or IBD were 3.5%, 4.6%, and 5.7% in the United Kingdom, Spain, and Sweden, respectively. CONCLUSIONS Potential linaclotide off-label use and misuse appears limited, as evidenced by the small sizes of the patient subgroups at risk for off-label use and misuse.
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Affiliation(s)
| | - Brian E. Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | | | | | | | | | - Ainhoa Gómez-Lumbreras
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | - Dan Ouchi
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | - Maria Giner-Soriano
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | | | - Daniel Pohl
- Neurogastroenterology and Motility, Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
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Shah ED, Brenner DM, Chen VL. Baseline Predictors of Discontinuation of Prescription Drug Therapy for IBS-C: Cohort Analysis at an Integrated Healthcare System. Dig Dis Sci 2022; 67:1213-1221. [PMID: 33779879 PMCID: PMC8478965 DOI: 10.1007/s10620-021-06963-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Effective prescription drug treatment of constipation-predominant irritable bowel syndrome (IBS-C) requires patients to remain on daily therapy, yet predictive factors to optimize treatment selection are unknown. AIMS We assessed whether common comorbidities including chronic overlapping pain conditions (COPCs), mood disorders, or concurrent medications influence the risk of discontinuing IBS-C prescription drug therapy. METHODS We included all IBS-C patients who initiated treatment with the secretagogues linaclotide or lubiprostone across the Michigan Medicine healthcare system between 2012 and 2016. A Cox proportional hazards model was constructed to model time-to-treatment discontinuation as a valid, quantifiable measure of IBS medication persistence using hazards ratios (HR) with 95% confidence intervals (CI). RESULTS Our cohort included 225 patients on linaclotide and 492 on lubiprostone (mean age 48.3 years, 86.9% women, 46.6% with at least one COPC, 60.3% with at least one mood disorder) with an average follow-up of 2.1 years. Patients with at least one COPC (HR = 0.566; 95%CI = 0.371-0.863) and also women (HR = 0.535; 95%CI = 0.307-0.934) had a lower risk of discontinuing linaclotide, while COPCs predicted a trend toward increased discontinuation of lubiprostone (HR = 1.254; 95%CI = 0.997-1.576). Age, comorbid mood disorders, and baseline use of narcotics or benzodiazepines did not significantly mediate the risk of treatment discontinuation; our findings remained stable in univariate and multivariable analyses. CONCLUSIONS COPCs and sex appear to influence the likelihood of discontinuation of two commonly prescribed secretagogues, while mood disorders, narcotics, and benzodiazepines may not. Routine assessment for comorbid COPCs prior to initiating therapy may optimize IBS-C treatment selection and outcomes in practice.
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Affiliation(s)
- Eric D. Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03766, USA,Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Darren M. Brenner
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vincent L. Chen
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
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Marlicz W, Skonieczna-Żydecka K, Krynicka P, Łoniewski I, Rydzewska G. Probiotics in irritable bowel syndrome - is the quest for the right strain over? Rapid review of existing guidelines and recommendations. PRZEGLAD GASTROENTEROLOGICZNY 2021; 16:369-382. [PMID: 34976247 PMCID: PMC8690954 DOI: 10.5114/pg.2021.111766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/30/2021] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) - functional gastrointestinal disorder (FGIDs) and disorder of gut-brain interaction (DGBIs) - has emerged as an important medical problem with an impact on health care systems, affecting patients' quality of life. The management of IBS consists of pharmacological and non-pharmacological treatments; however, the data of their long-term efficacy are scarce. Modulation of gastrointestinal microbiota, by means of probiotics and prebiotics, is often sought and advertised as a popular treatment modality in IBS. Faecal microbiota transplantation (FMT) awaits recommendations for IBS treatment and requires more methodological assessments. To date, numerous guidelines and recommendations have been published on the role of probiotics in IBS. Because no probiotic claim for probiotics in foods has yet been granted by the European Food and Safety Authority (EFSA), medical practitioners still recommend probiotics on the basis of available literature and recommendations released by independent health authorities. We aimed to summarize published formal recommendations and guidelines regarding the clinical effectiveness of available probiotic strains and conduct a random-effects meta-analysis of outcomes for which ≥ 2 studies contributed data on the same probiotic strain recommended to adults with IBS. Based on available and most recent guidelines, we report that probiotics, as a group, may be an effective treatment for global symptoms and abdominal pain in IBS, with the strongest effect for genus Lactobacillus. Our current and updated meta-analysis is in line with several reports documenting significant effects of Lactobacillus plantarum (Lp299v) in reducing the risk of global symptoms and their persistence, which could assist clinicians in making the choice for the right probiotic strain in IBS patients.
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Affiliation(s)
- Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | | | - Patrycja Krynicka
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Igor Łoniewski
- Department of Biochemical Sciences, Pomeranian Medical University, Szczecin, Poland
| | - Grażyna Rydzewska
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Unit, Central Clinical Hospital of the Ministry of the Inferior and Administration, Warsaw, Poland
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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Shah ED, Chang L, Lembo A, Staller K, Curley MA, Chey WD. Price Is Right: Exploring Prescription Drug Coverage Barriers for Irritable Bowel Syndrome Using Threshold Pricing Analysis. Dig Dis Sci 2021; 66:4140-4148. [PMID: 33433804 DOI: 10.1007/s10620-020-06806-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prescription drug costs exert profound effects on commercial insurance coverage and access to effective therapy. AIMS We aimed to assess threshold pricing to achieve budget neutrality of FDA-approved drugs treating irritable bowel syndrome from an insurance perspective, based on cost-savings resulting in decreased healthcare utilization through effective disease management. METHODS We constructed a decision-analytic model from an insurance perspective to assess the budget impact of IBS prescription drugs under usual insurance coverage levels in practice: (1) unrestricted drug access or (2) step therapy in a primary care population of middle-age, care-seeking IBS patients. Budget-neutral drug prices were then calculated which resulted in $0 budget impact to insurers with a short-term, one-year time horizon. RESULTS If used according to FDA labeling, IBS-D drugs cost between $4778 and $16,844 per year and IBS-C drugs cost between $4319 and $4955 per year. These drug costs often exceed insurance expenditures of $6999 for IBS-D and $3929 for IBS-C if left untreated. Therefore, for drugs to have $0 budget impact to insurers, their prices would need to be discounted 36.7-74.2% for IBS-D drugs and 59.3-82.5% for IBS-C. IBS drugs are already priced to support step therapy "failing one of several common, inexpensive IBS treatments with a responder rate > 30-40%," reflecting the subpopulation with more severe disease and greater healthcare costs. CONCLUSIONS Broader prescription drug coverage for patients failing common, inexpensive IBS treatments to which at least 30-40% of patients would typically respond appears warranted to enable gastroenterologists to offer personalized approaches targeting specific mechanisms of this heterogeneous disease.
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Affiliation(s)
- Eric D Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Anthony Lembo
- Digestive Disease Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Curley
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
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Diarrhea-Predominant and Constipation-Predominant Irritable Bowel Syndrome: Current Prescription Drug Treatment Options. Drugs 2021; 81:1953-1968. [PMID: 34727333 DOI: 10.1007/s40265-021-01634-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 12/14/2022]
Abstract
Irritable bowel syndrome (IBS) is a heterogenous disease with a variety of therapeutic options, including eight prescription drugs approved for use in IBS in the USA. Choosing among the myriad treatment options requires attention to patient preferences both on clinical outcomes and costs associated with treatment. We performed a narrative review of the literature to summarize these important determinants of treatment choice including: labeled indications; clinical profiles of efficacy, safety, and tolerability of prescription drugs; and cost-effectiveness for diarrhea-predominant IBS drugs (IBS-D: alosetron, eluxadoline, and rifaximin) and constipation-predominant IBS drugs (IBS-C: linaclotide, lubiprostone, plecanatide, tegaserod, and tenapanor). We then review the standard model of shared decision-making aimed at guiding an informed, patient-centered discussion to integrate comparative clinical and cost outcomes toward choosing an IBS treatment in practice.
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Evaluating the Impact of Cost on the Treatment Algorithm for Chronic Idiopathic Constipation: Cost-Effectiveness Analysis. Am J Gastroenterol 2021; 116:2118-2127. [PMID: 34388141 DOI: 10.14309/ajg.0000000000001403] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common and burdensome illness. We performed a cost-effectiveness analysis of the US Food and Drug Administration-approved CIC drugs to evaluate and quantify treatment preferences compared with usual care from insurer and patient perspectives. METHODS We evaluated the subset of patients with CIC and documented failure of over-the-counter (OTC) osmotic or bulk-forming laxatives. A RAND/UCLA consensus panel of 8 neurogastroenterologists informed model design. Treatment outcomes and costs were defined using integrated analyses of registered clinical trials and the US Centers for Medicare and Medicaid Services-supported cost databases. Quality-adjusted life years (QALYs) were calculated using health utilities derived from clinical trials. A 12-week time horizon was used. RESULTS With continued OTC laxatives, CIC-related costs were $569 from an insurer perspective compared with $3,154 from a patient perspective (considering lost wages and out-of-pocket expenses). CIC prescription drugs increased insurer costs by $618-$1,015 but decreased patient costs by $327-$1,117. Effectiveness of CIC drugs was similar (0.02 QALY gained/12 weeks or ∼7 healthy days gained/year). From an insurer perspective, prescription drugs (linaclotide, prucalopride, and plecanatide) seemed less cost-effective than continued OTC laxatives (incremental cost-effectiveness ratio >$150,000/QALY gained). From a patient perspective, the cost-effective algorithm started with plecanatide, followed by choosing between prucalopride and linaclotide starting at the 145-μg dose (favoring prucalopride among patients whose disease affects their work productivity). The patient perspective was driven by drug tolerability and treatment effects on quality of life. DISCUSSION Addressing costs at a policy level has the potential to enable patients and clinicians to move from navigating barriers in treatment access toward truly optimizing treatment choice.
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12
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Ooba N, Takahashi Y, Nagamura M, Takahashi M, Ushida M, Kawakami E, Kimura M, Sato T, Tokuyoshi J, Miyazaki C, Shimada M. Safety of elobixibat and lubiprostone in Japanese patients with chronic constipation: a retrospective cohort study. Expert Opin Drug Saf 2021; 20:1553-1558. [PMID: 34281471 DOI: 10.1080/14740338.2021.1952980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to discuss and compare reported adverse reactions and drug add-ons associated with elobixibat and lubiprostone use in chronic constipation treatment, as the safety of these drugs has not been well examined in post-marketing clinical settings. RESEARCH DESIGN AND METHODS In this retrospective cohort study, using records of community pharmacies in Japan, we identified new users of elobixibat and lubiprostone. The Japan Pharmaceutical Association sent questionnaires regarding baseline and event data to community pharmacists. The incidence of events and hazard ratio (HR) associated with the study drugs were evaluated. RESULTS New users of elobixibat (n = 979) and lubiprostone (n = 829) were identified (mean age: 74 and 77 years; females: 59% and 53%, respectively). Although the crude risk ratio of adverse events for elobixibat was 0.79 (95% confidence interval: 0.63-0.99), there was no significant difference in the HR for any of the common events, including drug add-ons (n ≥ 5), compared with those for lubiprostone. CONCLUSION No new safety concerns have been raised in relation to elobixibat and lubiprostone use for treating chronic constipation, although the HR of different events varied. Further larger-scale study is needed as the estimates for events of small numbers were unstable.
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Affiliation(s)
- Nobuhiro Ooba
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Chiba, Japan
| | | | - Marina Nagamura
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Chiba, Japan
| | | | | | | | - Masaomi Kimura
- Department of Computer Science and Engineering, Shibaura Institute of Technology, Tokyo, Japan
| | - Tsugumichi Sato
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
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13
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Chesnel C, Hentzen C, Haddad R, Charlanes A, Le Breton F, Turmel N, Amarenco G. Adherence to transanal irrigation in older adults: first-year assessment. Tech Coloproctol 2021; 25:1055-1063. [PMID: 34185193 DOI: 10.1007/s10151-021-02479-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 06/09/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While the prevalence of chronic constipation and fecal incontinence increases with age, few data on transanal irrigation in older adults are available. The aim of this study was to assess the adherence and predictive factors for adherence to transanal irrigation during the first year of use in older adults. METHODS This retrospective study included all patients over 65 years old, who had therapeutic education for transanal irrigation with the Peristeen® device between January 2010 and July 2019 in a neuro-urology department of a university hospital in France. The adherence rate was assessed at 1, 3, 6, and 12 months. Predictive factors for adherence were looked for by comparing persistent population and non-persistent population at 1, 3, 6, and 12 months. RESULTS Sixty-nine patients over 65 years old were included. The adherence rate was 73.9% at 1 month, 55.1% at 3 months, 46.4% at 6 months, and 40.1% at 1 year. No predictive factor for adherence to transanal irrigation was identified. CONCLUSIONS Adherence to transanal irrigation during the first year in older adults remains close to that in the adult general population. Predictive factors of adherence remain unclear.
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Affiliation(s)
- C Chesnel
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France. .,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France. .,GRAPPPA (Clinical Research Group of Perineal Dysfunctions in Older Adults), Department of Neuro-Urology, Tenon Hospital, Paris, France.
| | - C Hentzen
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France.,GRAPPPA (Clinical Research Group of Perineal Dysfunctions in Older Adults), Department of Neuro-Urology, Tenon Hospital, Paris, France
| | - R Haddad
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France.,GRAPPPA (Clinical Research Group of Perineal Dysfunctions in Older Adults), Department of Neuro-Urology, Tenon Hospital, Paris, France
| | - A Charlanes
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France.,GRAPPPA (Clinical Research Group of Perineal Dysfunctions in Older Adults), Department of Neuro-Urology, Tenon Hospital, Paris, France
| | - F Le Breton
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France
| | - N Turmel
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France.,GRAPPPA (Clinical Research Group of Perineal Dysfunctions in Older Adults), Department of Neuro-Urology, Tenon Hospital, Paris, France
| | - G Amarenco
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Department of Neuro-Urology, Tenon Hospital, 4, rue de la Chine, 75020, Paris, France.,GRAPPPA (Clinical Research Group of Perineal Dysfunctions in Older Adults), Department of Neuro-Urology, Tenon Hospital, Paris, France
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Contrasting Clinician and Insurer Perspectives to Managing Irritable Bowel Syndrome: Multilevel Modeling Analysis. Am J Gastroenterol 2021; 116:748-757. [PMID: 33982945 DOI: 10.14309/ajg.0000000000000989] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Insurance coverage is an important determinant of treatment choice in irritable bowel syndrome (IBS), often taking precedence over desired mechanisms of action or patient goals/values. We aimed to determine whether routine and algorithmic coverage restrictions are cost-effective from a commercial insurer perspective. METHODS A multilevel microsimulation tracking costs and outcomes among 10 million hypothetical moderate-to-severe patients with IBS was developed to model all possible algorithms including common global IBS treatments (neuromodulators; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) and prescription drugs treating diarrhea-predominant IBS (IBS-D) or constipation-predominant IBS (IBS-C) over 1 year. RESULTS Routinely using global IBS treatments (central neuromodulator; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) before US Food and Drug Administration-approved drug therapies resulted in per-patient cost savings of $9,034.59 for IBS-D and $2,972.83 for IBS-C over 1 year to insurers, compared with patients starting with on-label drug therapy. Health outcomes were similar, regardless of treatment sequence. Costs varied less than $200 per year, regardless of the global IBS treatment order. The most cost-saving and cost-effective IBS-D algorithm was rifaximin, then eluxadoline, followed by alosetron. The most cost-saving and cost-effective IBS-C algorithm was linaclotide, followed by either plecanatide or lubiprostone. In no scenario were prescription drugs routinely more cost-effective than global IBS treatments, despite a stronger level of evidence with prescription drugs. These findings were driven by higher prescription drug prices as compared to lower costs with global IBS treatments. DISCUSSION From an insurer perspective, routine and algorithmic prescription drug coverage restrictions requiring failure of low-cost behavioral, dietary, and off-label treatments appear cost-effective. Efforts to address insurance coverage and drug pricing are needed so that healthcare providers can optimally care for patients with this common, heterogenous disorder.
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15
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Shah ED, Salwen-Deremer JK, Gibson PR, Muir JG, Eswaran S, Chey WD. Pharmacologic, Dietary, and Psychological Treatments for Irritable Bowel Syndrome With Constipation: Cost Utility Analysis. MDM Policy Pract 2021; 6:2381468320978417. [PMID: 33521290 PMCID: PMC7818007 DOI: 10.1177/2381468320978417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/28/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction. Irritable bowel syndrome (IBS) is the most common gastroenterology referral and one of the most common gastrointestinal complaints in primary care. We performed a cost-utility analysis of the most common treatments available in general practice for IBS with constipation (IBS-C), the most expensive IBS subtype. Methods. We developed a decision analytic model evaluating guideline-recommended and Food and Drug Administration-approved drugs, supplements, and dietary/psychological interventions. Model inputs were derived from "global symptom improvement" outcomes in systematic reviews of clinical trials. Costs were derived from national datasets. Analysis was performed with a 1-year time horizon from patient and payer perspectives. We analyzed a prototypical managed-care health plan with no cost-sharing to the patient. Results. From a payer perspective, global IBS treatments (including low FODMAP, cognitive behavioral therapy [CBT], neuromodulators), which are not specific to the IBS-C bowel subtype were less expensive than on-label prescription drug treatments. From a patient perspective, on-label prescription drug treatment with linaclotide was the least expensive treatment strategy. Drug prices and costs to manage untreated IBS-C were most important determinants of payer treatment preferences. Effects of treatment on missed work-days and need for repeated appointments to complete treatment were the most important determinants of treatment preference to patients. Discussion. Due mostly to prescription drug prices, neuromodulators, low FODMAP, and CBT appear cost-effective compared to on-label drug treatments from a payer perspective in cost-utility analysis. These findings may explain common treatment barriers in clinical practice.
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Affiliation(s)
- Eric D. Shah
- Eric D. Shah, Center for Gastrointestinal
Motility, Esophageal, and Swallowing Disorders, Dartmouth-Hitchcock Medical
Center, One Medical Center Drive, Lebanon, NH 03766, USA; telephone: (603)
650-5261 ()
| | - Jessica K. Salwen-Deremer
- Section of Gastroenterology and Hepatology,
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Psychiatry, Dartmouth-Hitchcock
Medical Center, Lebanon, New Hampshire
| | - Peter R. Gibson
- Department of Gastroenterology, Central Clinical
School, Monash University, Melbourne, Victoria, Australia
| | - Jane G. Muir
- Department of Gastroenterology, Central Clinical
School, Monash University, Melbourne, Victoria, Australia
| | - Shanti Eswaran
- Division of Gastroenterology, Michigan Medicine,
Ann Arbor, Michigan
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine,
Ann Arbor, Michigan
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16
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Shah ED, Ballou SK. Health Economic Studies Are Important for Patients With Irritable Bowel Syndrome and Their Gastroenterologists. Clin Gastroenterol Hepatol 2021; 19:43-45. [PMID: 32434066 DOI: 10.1016/j.cgh.2020.05.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Eric D Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Sarah K Ballou
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
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