Constipation-predominant irritable bowel syndrome: A review of current and emerging drug therapies

Pharmacokinetics and bioequivalence assessment of two prucalopride formulations in healthy Chinese women: a randomized, open-label, two-period, two-sequence, self-crossover study

Objective

This study aimed to evaluate the pharmacokinetic (PK) bioequivalence of generic and branded prucalopride formulations.

Methods

Twenty-four healthy female subjects were enrolled in both fasted and fed trials, with each subject receiving either the test (generic) or reference (branded) formulation after an overnight fast. Blood samples were collected up to 72 h post-administration. Plasma concentrations of prucalopride were quantified using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS), and the corresponding PK parameters were subsequently calculated. Clinical safety data were monitored throughout the trial period.

Results

All 24 subjects completed both the fasted and fed trials. No significant differences were found in the PK data between the test and reference formulations for either the fasted or fed states. The Wilcoxon signed-rank test of Tmax revealed no significant differences between the two formulations in both the fasted (P = 0.319) and fed (P = 0.973) states. The 90% confidence intervals (CIs) for the bioequivalence parameters fell within the 80%-125% range, which meets the standard bioequivalence acceptance criteria. Additionally, there were no significant differences in the incidence of adverse events (AEs) between the generic and branded formulations, and no serious AEs were reported throughout the trial period.

Conclusion

The generic and branded prucalopride tablets were bioequivalent in terms of PK parameters and demonstrated no clinically relevant differences in safety outcomes.

Clinical Trial Registration

http://www.chinadrugtrials.org.cn/clinicaltrials.prosearch.dhtml, identifier CTR20232669.

The Efficacy of Lubiprostone in Patients of Constipation: An Updated Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Lubiprostone increases chloride and water secretion in the intestines, and several studies have demonstrated the efficacy of lubiprostone in treating functional constipation. Several new clinical trials have emerged since the previous meta-analysis conducted in 2020. We conducted this updated meta-analysis to assess clinical efficacy of lubiprostone in these patients.

METHODS

A systematic search was conducted on MEDLINE, Cochrane, and Scopus. Randomized controlled trials published between July 2019 and June 2024 were selected. Cochrane's RoB 2 tool was used to assess the risk of bias. A meta-analysis was performed and findings were presented using forest plots.

RESULTS

A total of 14 studies, comprising 4550 patients, were included in the review. Only 12 studies were pooled in the meta-analysis. Lubiprostone was associated with greater spontaneous bowel movements (SBM) per week (RR 1.454, 95% CI 1.193-1.771) and SBM within 24 h (RR 1.790, 95% CI 1.491-2.150) in patients with chronic idiopathic constipation (CIC). However, it was not associated with abdominal pain in either arm (RR 1.415, 95% CI 0.873-2.294). In opioid-induced constipation (OIC), lubiprostone increased SBM within 24 h (RR 1.277, 95% CI 1.105-1.475) but did not significantly affect abdominal pain (RR 4.321, 95% CI 0.624-29.941). Lubiprostone improved all selected SBM-related and abdominal pain outcomes in patients with irritable bowel syndrome with constipation (IBS-C).

CONCLUSION

Lubiprostone significantly improves all SBM-related outcomes. Owing to its good safety and efficacy profile, lubiprostone can be used in the combination regimens for management of CIC, IBS-C, and OIC.

Acacia fiber or probiotic supplements to relieve gastrointestinal complaints in patients with constipation-predominant IBS: a 4-week randomized double-blinded placebo-controlled intervention trial

PURPOSE

To date, no adequate treatment for irritable bowel syndrome with predominant constipation complaints (IBS-C) is available. Fibers with prebiotic properties and probiotic compounds have shown promise in relieving IBS-C-related complaints. We aimed to determine the effects of a 4-week intervention with either an Acacia fiber (AF) with prebiotic properties or a probiotic Bifidobacterium Lactis (BLa80) supplement, compared to a control supplement, on stool pattern, IBS symptoms and Quality of Life (QoL), in IBS-C individuals.

METHODS

A parallel, double-blind, randomized controlled trial involving 180 subjects meeting the ROME IV criteria for IBS-C was conducted. Following a 4-week observation period, subjects received either AF (10 g), Probiotic BLa80 (4 g; 2 × 1011 CFU/g) or a maltodextrin placebo (10 g) daily for 4 weeks. Subjects reported daily information on stool pattern and gastrointestinal complaints. Before and after each 4-week period, questionnaires on symptom severity, constipation symptoms, anxiety and depression and QoL were completed. Stool mass was measured for 5-days before and after the intervention.

RESULTS

Stool frequency significantly improved in the AF and Probiotic BLa80 groups compared to placebo (P < 0.001, P = 0.02, respectively). Probiotic BLa80 showed a significant reduction in IBS symptom severity (P = 0.03), for AF a trend towards decreased constipation symptoms (PAC-SYM, P = 0.10) was observed. No significant changes in stool consistency, stool mass or QoL measures were observed between the AF and Probiotic BLa80 compared to placebo.

CONCLUSION

Daily dietary supplementation with Acacia fiber and probiotic supplements might help IBS-C patients by relieving IBS-related complaints compared to a placebo supplement.

REGISTRATION NUMBER OF CLINICAL TRIAL

The trial is registered at ClinicalTrials.gov: NCT04798417: Study Details | Nutrition to Relieve IBS Constipation | ClinicalTrials.gov.

Efficacy and Safety of the Adjuvant Use of Probiotic Bacillus clausii Strains in Pediatric Irritable Bowel Syndrome: A Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVES

Current irritable bowel syndrome (IBS) treatments have limited efficacy and probiotics like Bacillus clausii (B. clausii) were found to be effective in the management of several gastrointestinal disorders. This phase III trial assessed the efficacy and safety of adding B. clausii (four strains: O/C, N/R, SIN, T), versus placebo, to conventional treatment of pediatric IBS in Mexico.

METHODS

Patients aged 6-17 years 11 months with IBS (Rome IV) for at least 2 months were randomized to receive either B. clausii (oral suspension, total dose 4 billion spores/day) or placebo once daily for 8 weeks. All patients also received conventional treatment. The primary endpoint was the difference in the proportion of patients with clinical improvements at Week 8 (Global Assessment Questions [GAQ]). Secondary endpoints included responders by Subject's Global Assessment of Relief for Children with IBS (SGARC); number/consistency of stools; abdominal distention/bloating; abdominal pain/intensity; and IBS behavior.

RESULTS

73.6% (95% confidence interval [CI] 67.3-80.0; B. clausii n = 129) and 78.5% (95% CI 72.5-84.4; placebo n = 130) of patients had symptom improvement (p = 0.8182). For Week 8 SGARC, 19.2% (B. clausii) and 20.9% (placebo) reported complete symptom relief. Stool evaluations, bloating, abdominal pain/intensity, and IBS behavior were similar between groups. Both treatments were well tolerated.

CONCLUSION

No significant differences in efficacy between B. clausii and placebo were demonstrated in addition to conventional treatment. The sample size calculation was based on an expected placebo/conventional treatment response of 30-40%. However, the actual treatment response observed was 80% and, thus, a study with larger population would be warranted. In addition, this study was conducted during the COVID-19 pandemic, when such controlled social conditions may have resulted in better diet, greater family stability, less psychological stress, and lower risk of infections exacerbating IBS, thereby improving symptoms in both groups.

EUDRACT NUMBER

2018-004519-31.

Tegaserod for the Treatment of Irritable Bowel Syndrome

Background: Tegaserod (Zelnorm®) is a 5-hydroxytryptamine (serotonin) type 4 receptor agonist for the treatment of hypomotility disorders of the lower gastrointestinal tract associated with the irritable bowel syndrome with constipation (IBS-C).

Objective: The authors provide the reader with a better understanding on tegaserod mechanism of action, on its pharmacodynamics and pharmacokinetic properties, on safety and tolerability, with a summary of the key published clinical trials conducted in patients with irritable bowel syndrome (IBS). Its effects on colon inflammation have also been described.

Results: Tegaserod was withdrawn in 2007 due to increased risks of cardiovascular adverse effects. The manufacturer denied this, because pre-existing cardiovascular disease or risk factors were attributed to all affected patients. Thus, no causal relationship between tegaserod use and cardiovascular events was clearly shown. A matched case-control study of tegaserod-treated with untreated patients found no association between tegaserod and adverse cardiovascular outcomes. Despite its adverse effects, tegaserod resulted to be effective in treating chronic constipation in adult women aged < 65 years with IBS-C, while the safety and effectiveness of tegaserod in men with IBS-C have not been established.

Conclusion: Tegaserod was resubmitted to the Food and Drug Administration in 2018 for use in a low-risk population. Moreover, tegaserod has also been shown to improve symptoms, enhance gastric accommodation and significantly attenuate visceral pain arising from the colon in functional dyspepsia patients. Treatment with tegaserod seems also to exert a protective effect in inflamed colons, reducing the severity of colitis in animal models.

Irritable Bowel Syndrome: News from an Old Disorder

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder, which can affect all members of a society, regardless of age, sex, race or socioeconomic status. Because of its high prevalence and chronic nature, it represents a significant economic burden. In fact, these patients have a relevant impairment of their quality of life, which limits their work productivity and daily social activities, especially when it is associated with other disorders, such as anxiety and depression. The diagnosis of IBS relies on symptom-based diagnostic criteria with normal results on a limited number of complementary tests that rule out other possible diagnoses. The aetiology of this condition is incompletely established. However, evidence suggests that it is a multifactorial disorder with several different mechanisms that have been implicated as responsible for the symptoms. Since the treatment strategy is usually based on predominant symptoms and their severity, it is important to recognise the underlying mechanisms in order to successfully relief the visceral pain and altered bowel habits. The aim of this non-systematic review of the literature was to explore the pathophysiology and treatment options of IBS, highlighting the most recent evidence, from the new Rome IV criteria to the new drug armamentarium.

Economic burden of moderate to severe irritable bowel syndrome with constipation in six European countries

Background

Irritable bowel syndrome with predominant constipation (IBS-C) is a complex disorder with gastrointestinal and nervous system components. The study aim was to assess the economic burden of moderate to severe IBS-C in six European countries (France, Germany, Italy, Spain, Sweden and the UK).

Methods

An observational, one year retrospective-prospective (6 months each) study of patients diagnosed in the last five years with IBS-C (Rome III criteria) and moderate to severe disease at inclusion (IBS Symptom Severity Scale score ≥ 175). The primary objective was to assess the direct cost to European healthcare systems.

Results

Five hundred twenty-five patients were included, 60% (range: 43.1–78.8%) suffered from severe IBS-C. During follow-up 11.1–24.0% of patients had a hospitalisation/emergency room (ER) visit, median stay range: 1.5–12.0 days and 41.1–90.4% took prescription drugs for IBS-C. 21.4–50.8% of employed patients took sick leave (mean: 11.6–64.1 days). The mean annual direct cost to the healthcare systems was €937.1- €2108.0. The total direct cost (combined costs to healthcare systems and patient) for IBS-C was €1421.7–€2487.1.

Conclusions

IBS-C is not a life-threatening condition; however, it has large impact on healthcare systems and society. Direct and indirect costs for moderate to severe IBS-C were high with the largest direct cost driver being hospitalisations/ER visits.

Brain-Gut Axis: Clinical Implications

This article provides an overarching view of what is currently known about the physiology of the brain-gut axis in both health and disease and how these concepts apply to irritable bowel syndrome, the most common functional gastrointestinal disorder in pediatrics.

Value of lactulose combined with prucalopride in treatment of refractory constipation in elderly patients with subarachnoid hemorrhage

AIM

To observe the clinical value of prucalopride combined with lactulose in the management of refractory constipation in elderly patients with subarachnoid hemorrhage.

METHODS

The subjects were 70 patients with congestive subarachnoid hemorrhage complicated with refractory constipation, who were admitted to our hospital from May 2013 to May 2017. They were divided into either an observation group (30 patients) to receive lactulose combined with prucalopride or a control group (40 patients) to receive lactulose combined with mosapride. Then, the two groups of patients were compared in defecation difficulty score, stool character score, defecation time, weekly defecation frequency, and therapeutic effects.

RESULTS

Before treatment, there was no significant difference in defecation difficulty score, stool character score, defecation time, weekly defecation frequency, or other indexes between the two groups (P > 0.05). After treatment, the defecation difficulty score and defecation time were significantly lower in the observation group than in the control group (3.67± 1.31 vs 6.35 ± 2.11, 10.56 min ± 2.36 min vs 37.09 min ± 8.21 min, P < 0.05). The stool character score and weekly defecation frequency were significantly higher in the observation group than in the control group (4.68 ±0.96 vs 2.22 ± 0.98, 5.25 ± 1.28 vs 1.71 ± 0.81, P < 0.05). The total effective rate was significantly higher in the observation group than in the control group (93.33% vs 77.5%, P < 0.05). The incidence of recurrent rupture of intracranial aneurysms and death was significantly lower in the observation group than in the control group (3.33% vs 17.5%, 3.33% vs 20%, P < 0.05).

CONCLUSION

Prucalopride combined with lactulose has a significant effect in the treatment of refractory constipation in elderly patients with congenital subarachnoid hemorrhage, and can reduce the incidence of intracranial aneurysm rupture and improve the prognosis of patients.

Saccharomyces cerevisiae CNCM I-3856 in irritable bowel syndrome: An individual subject meta-analysis

AIM

To confirm previous conclusions on Saccharomyces cerevisiae (S. cerevisiae) CNCM I-3856 for irritable bowel syndrome (IBS) management.

METHODS

An individual patient data meta-analysis was performed on two randomized clinical trials studying the effect of S. cerevisiae CNCM I-3856 supplementation on gastrointestinal (GI) symptoms in IBS subjects. A total of 579 IBS subjects were included. Outcomes were the daily Likert scale scores of abdominal pain/discomfort and bloating [area under the curve (AUC) and weekly means], responder status, and bowel movements (stool frequency and consistency). Statistical analyses were conducted in Intent to Treat (ITT) population, IBS-C subjects and IBS-C subjects with an abdominal pain/discomfort score higher than or equal to 2 at baseline ("IBS-C ≥ 2 subpopulation").

RESULTS

S. cerevisiae CNCM I-3856 significantly improved abdominal pain/discomfort and bloating during the second month of supplementation [AUC (W5-W8)] with improvement up to the minimal clinically relevant threshold of 10%: a 12.3% reduction of abdominal pain/discomfort in the ITT population compared to the Placebo group (P = 0.0134) has been observed. In the IBS-C ≥ 2 subpopulation, there were a 13.1% reduction of abdominal pain/discomfort and a 14.9% reduction of bloating compared to the Placebo group (P = 0.0194 and P = 0.0145, respectively). GI symptoms significantly decreased during supplementation but no statistical differences were reported between groups at the end of the supplementation period. Responder status was defined as a subject who experienced a decrease of 1 arbitrary unit (a.u.) or 50% of the abdominal discomfort score from baseline for at least 2 wk out of the last 4 wk of the study. A significant difference between groups was reported in the ITT population, when considering the first definition: subjects in the Active group had 1.510 higher odds to be a responder (reduction of 1 a.u. of abdominal pain/discomfort) compared with subjects in the Placebo group (P = 0.0240). At the end of supplementation period, stool consistency in the Active group of the ITT population was significantly improved and classified as "normal" compared to Placebo (respectively 3.13 ± 1.197 a.u. vs 2.58 ± 1.020 a.u., P = 0.0003). Similar results were seen in the IBS-C ≥ 2 subpopulation (Active group: 3.14 ± 1.219 a.u. vs Placebo group: 2.59 ± 1.017 a.u., P = 0.0009).

CONCLUSION

This meta-analysis supports previous data linking S. cerevisiae I-3856 and improvement of GI symptoms, in IBS overall population and in the IBS-C and IBS-C ≥ 2 subpopulations.

Effects of baseline abdominal pain and bloating on response to lubiprostone in patients with irritable bowel syndrome with constipation

BACKGROUND

Lubiprostone (8 μg b.d.) received US Food and Drug Administration (FDA) approval in 2008 for the treatment of constipation-predominant irritable bowel syndrome (IBS-C) in women aged ≥18 years. In 2012, the FDA issued new guidance for IBS-C clinical trials, recommending a composite endpoint incorporating both abdominal pain and stool frequency.

AIM

In a post hoc analysis, similar criteria were applied to data from two pivotal, phase 3, double-blind, randomised trials of lubiprostone in patients with IBS-C.

METHODS

Included patients had a baseline spontaneous bowel movement (SBM) frequency <3/week and abdominal pain or bloating ratings ≥1.36 on a 5-point scale [0 (absent) to 4 (very severe)]. Responders (composite endpoint) had a mean pain reduction ≥30% compared with baseline, and an increase from baseline of ≥1 SBM/week for ≥6 of the 12 treatment weeks. Lubiprostone effects on abdominal pain alone were also evaluated, as were bloating alone and in a composite endpoint with stool frequency.

RESULTS

In pooled data, 325 patients received lubiprostone and 180 received placebo. Rates of response were higher with lubiprostone vs. placebo for the composite endpoint of improved pain and stool frequency (26.3% vs. 15.3%, respectively; P = 0.008) and the composite endpoint of improved bloating and stool frequency (23.8% vs. 12.6%, respectively; P = 0.012). Response rates were also higher with lubiprostone vs. placebo for abdominal pain alone (P = 0.005) and bloating alone (P = 0.012).

CONCLUSION

Lubiprostone was significantly more effective than placebo in improving abdominal pain or bloating, and also in composite endpoints that included stool frequency.

Curative effect of mosapride vs prucalopride in treatment of chronic constipation in elderly patients

AIM: To compare the curative effect between mosapride and prucalopride in the treatment of chronic constipation in elderly patients.

METHODS: From February 2013 to September 2014, 123 elderly patients with chronic constipation at our department were randomly assigned to orally receive either mosapride (control group, n = 61) or prucalopride (observation group, n = 62). The efficacy, time to first defecation, and time to improvement of difficult defecation were compared between the two groups. Moreover, the scores for common symptoms (defecation frequency, stool properties, defecation difficulty and defecation time) and adverse reactions were also recorded.

RESULTS: The total effective rate in the observation group was 83.61% (59/62), significantly higher than that of the control group [83.61% (51/61), P < 0.05]. Compared with the control group, the time to first defecation and time to improvement of difficult defecation were shortened, and common symptom scores decreased in the observation group (P < 0.05). Main adverse reactions included diarrhea, nausea and abdominal pain, and the duration of these adverse reactions was shorter. There was no statistical significance in the incidence of adverse reactions between the two groups (P > 0.05).

CONCLUSION: Prucalopride has a better curative effect than mosapride in the treatment of elderly patients with chronic constipation in terms of improved symptoms and tolerable adverse reactions.

Effect of the probiotic strain Bifidobacterium animalis subsp. lactis, BB-12®, on defecation frequency in healthy subjects with low defecation frequency and abdominal discomfort: a randomised, double-blind, placebo-controlled, parallel-group trial

The aim of the present study was to investigate the effect of Bifidobacterium animalis subsp. lactis, BB-12^®, on two primary end points – defecation frequency and gastrointestinal (GI) well-being – in healthy adults with low defecation frequency and abdominal discomfort. A total of 1248 subjects were included in a randomised, double-blind, placebo-controlled trial. After a 2-week run-in period, subjects were randomised to 1 or 10 billion colony-forming units/d of the probiotic strain BB-12^® or a matching placebo capsule once daily for 4 weeks. Subjects completed a diary on bowel habits, relief of abdominal discomfort and symptoms. GI well-being, defined as global relief of abdominal discomfort, did not show significant differences. The OR for having a defecation frequency above baseline for ≥50 % of the time was 1·31 (95 % CI 0·98, 1·75), P=0·071, for probiotic treatment overall. Tightening the criteria for being a responder to an increase of ≥1 d/week for ≥50 % of the time resulted in an OR of 1·55 (95 % CI 1·22, 1·96), P=0·0003, for treatment overall. A treatment effect on average defecation frequency was found (P=0·0065), with the frequency being significantly higher compared with placebo at all weeks for probiotic treatment overall (all P<0·05). Effects on defecation frequency were similar for the two doses tested, suggesting that a ceiling effect was reached with the one billion dose. Overall, 4 weeks’ supplementation with the probiotic strain BB-12^® resulted in a clinically relevant benefit on defecation frequency. The results suggest that consumption of BB-12^® improves the GI health of individuals whose symptoms are not sufficiently severe to consult a doctor (ISRCTN18128385).

Stress-induced visceral pain: toward animal models of irritable-bowel syndrome and associated comorbidities

Visceral pain is a global term used to describe pain originating from the internal organs, which is distinct from somatic pain. It is a hallmark of functional gastrointestinal disorders such as irritable-bowel syndrome (IBS). Currently, the treatment strategies targeting visceral pain are unsatisfactory, with development of novel therapeutics hindered by a lack of detailed knowledge of the underlying mechanisms. Stress has long been implicated in the pathophysiology of visceral pain in both preclinical and clinical studies. Here, we discuss the complex etiology of visceral pain reviewing our current understanding in the context of the role of stress, gender, gut microbiota alterations, and immune functioning. Furthermore, we review the role of glutamate, GABA, and epigenetic mechanisms as possible therapeutic strategies for the treatment of visceral pain for which there is an unmet medical need. Moreover, we discuss the most widely described rodent models used to model visceral pain in the preclinical setting. The theory behind, and application of, animal models is key for both the understanding of underlying mechanisms and design of future therapeutic interventions. Taken together, it is apparent that stress-induced visceral pain and its psychiatric comorbidities, as typified by IBS, has a multifaceted etiology. Moreover, treatment strategies still lag far behind when compared to other pain modalities. The development of novel, effective, and specific therapeutics for the treatment of visceral pain has never been more pertinent.

Optimal management of constipation associated with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common chronic functional disorder of the gastrointestinal tract, meanly characterized by recurrent abdominal pain or discomfort and altered bowel habit. It is a complex disorder involving biological, environmental, and psychosocial factors. The diagnosis is achieved according to the Rome III criteria provided that organic causes have been excluded. Although IBS does not constitute a life-threatening condition, it has a remarkable prevalence and profoundly reduces the quality of life with burdening socioeconomic costs. One of the principal concerns about IBS is the lack of effective therapeutic options. Up to 40% of patients are not satisfied with any available medications, especially those suffering from chronic constipation. A correct management of IBS with constipation should evolve through a global approach focused on the patient, starting with careful history taking in order to assess the presence of organic diseases that might trigger the disorder. Therefore, the second step is to examine lifestyle, dietary habits, and psychological status. On these bases, a step-up management of disease is recommended: from fiber and bulking agents, to osmotic laxative drugs, to new molecules like lubiprostone and linaclotide. Although new promising tools for relief of bowel-movement-related symptoms are being discovered, a dedicated doctor-patient relationship still seems to be the key for success.