Asociación Española de Neurogastroenterología y Motilidad (ASENEM) updated review on the management of functional abdominal pain

Functional abdominal pain is a disorder in which central and peripheral sensitization processes converge, leading to hypersensitivity and allodynia. Differential diagnosis is made with organic digestive, renal, gynecological, endocrine, or neurological diseases. Treatment should be individualized for each patient. In cases of debilitating pain, therapy combining drugs with different mechanisms of action can be initiated, while in less severe cases, therapy with a progressive introduction of drugs based on clinical response is advised. The first line includes general lifestyle advice and antispasmodic substances, like peppermint oil, anticholinergic/antimuscarinic, and calcium channels antagonists. In the second line of treatment, neuromodulating agents are added. Finally, when these measures fail, third-line treatments such as gabapentine and atypical antipsychotics are considered. Psychological interventions should be considered if specialized therapists are available to manage these disorders.

Spectrofluorimetric Protocol for Estimation of Commonly Used Antispasmodic Drotaverine. Fluorescence Quenching Study

A fast, simple, accurate, precise, and cheap fluorimetric protocol has been proposed for analysis of a phosphodiesterase-IV inhibitor, namely drotaverine hydrochloride. Fluorimetric protocol is based on estimating the decrease in the eosin Y fluorescence intensity by quantitative addition of drotaverine at pH 3.1 (acetate buffer). An ion pair complex is formed, which leads to quenching in the fluorescence intensity of the dye without need of prior extraction at 534 nm (λex. 339 nm). Different reaction perimeters which influence the production of complex (ion pair between drotaverine and eosin) were deeply investigated and optimized. The developed fluorimetric protocol is capable for quantitative estimation of drotaverine in linear range of 0.4 to 2.5 µg mL-1. After method validation in respect to ICH guidelines, it was applied to determine drotaverine in its commercial preparation. By comparing with other reported method, the developed and validated fluorimetric protocol is capable for estimation of drotaverine in commercial preparation with good accuracy and excellent precision.

AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Diarrhea

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder associated with significant disease burden. This American Gastroenterological Association Guideline is intended to support practitioners in decisions about the use of medications for the pharmacological management of IBS with predominant diarrhea (IBS-D) and is an update of a prior technical review and guideline.

METHODS

The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The technical review panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and conducted an evidence review of the following agents: eluxadoline, rifaximin, alosetron, loperamide, tricyclic antidepressants, selective serotonin reuptake inhibitors, and antispasmodics. The guideline panel reviewed the evidence and used the Evidence-to-Decision Framework to develop recommendations.

CONCLUSIONS

The panel agreed on 8 recommendations for the management of patients with IBS-D. The panel made conditional recommendations for eluxadoline, rifaximin, alosetron, (moderate certainty), loperamide (very low certainty), tricyclic antidepressants, and anstispasmodics (low certainty). The panel made a conditional recommendation against the use of selective serotonin reuptake inhibitors (low certainty).

Efficacy of hyoscine butyl-bromide in shortening the active phase of labor: Systematic review and meta-analysis of randomized trials

INTRODUCTION

Prolonged labor increases the risk of maternal and fetal complications. The active management of labor has been proven effective in lowering neonatal and maternal morbidity by shortening the duration of labor. Several pharmaceutical and non-pharmaceutical approaches are currently being used in the active management of labor. Hyoscine Butyl-bromide (HBB) is an antispasmodic and anticholinergic drug that acts as a cervical spasmolytic agent. It has been widely used in everyday practice for shortening the active phase of labor. Nonetheless, only a few trials have been conducted on the topic.

OBJECTIVE

This review aimed to evaluate whether HBB is effective in decreasing the mean duration of the active phase of labor.

STUDY DESIGN

An electronic search was conducted on Medline (through PubMed), Scopus, ClinicalTrials.gov, EMBASE, PROSPERO, and Cochrane Library from the beginning of all databases to December 2019. Results were limited to randomized trials. Restriction for English language was applied. Inclusion criteria were: randomized clinical trials regarding primiparae or multiparae women with a singleton vertex pregnancy at term who were randomized to HBB versus placebo or other drugs. Primary outcome evaluated was the mean reduction of the active phase of labor.

DATA COLLECTION AND ANALYSIS

Eight randomized clinical trials, including 1159 pregnant women, were analyzed. Significant heterogeneity (I² = 99 %) between studies was noted for the primary outcome. The active phase of labor duration was significantly reduced in the treatment arm compared to controls [mean difference (MD) -83.93 min (95 % confidence interval (CI) -163.61, -4.25)]. Achieved reduction in primiparae women was -55.09 min [95 % CI -68.83, -41.35; I² = 37 %].

CONCLUSION

HBB is an effective treatment to shorten the duration of the active phase of labor in primiparae and multiparae women.

Use of an antiemetic to shorten the length of labor in nulliparous women, exploring a potential role of an old drug: A randomized controlled trial

OBJECTIVE

To assess whether metoclopramide is effective in shortening the duration of the first stage of labor in primiparous women.

METHODS

The present randomized, double-blind, placebo-controlled trial was conducted at King Faisal Hospital, Saudi Arabia (between July 30, 2013, and September 1, 2016), and sequentially recruited young nulliparous women admitted in spontaneous active labor with or without ruptured membranes. Eligible participants were randomly assigned to receive a slow intravenous injection of either metoclopramide or placebo and consistently managed according to the local institutional intrapartum protocol and received identical monitoring and supportive care. The primary outcome was the cervical dilatation rate.

RESULTS

Fifty-nine women were included in the metoclopramide group and 52 in the placebo group. The first stage of labor was significantly shorter in the metoclopramide group (203 minutes vs 230 minutes in the placebo group, P=0.019), with a faster cervical dilatation rate (2.4 ± 0.4 cm/h vs 1.9 ± 0.5 cm/h in the placebo group, P<0.001) and shorter interval from treatment administration until full cervical dilatation. There was a significantly higher probability of faster delivery among women who were treated with metoclopramide (log-rank test, χ² =5.997, P=0.014).

CONCLUSION

Metoclopramide safely reduced the duration of the first stage of labor and was not associated with major maternal or neonatal adverse outcomes. CLINICALTRIALS.GOV: NCT01937234.

Prescription drug suicide in non-abusers: A 6-year forensic survey

BACKGROUND

Prescription drug suicide merits study to guide the development of strategies to reduce suicide risk. We examined prescription drug suicide specifically in non-abusers of prescription drugs; this is a relatively unexplored subject.

METHODS

Six-year data on prescription drug suicide in non-abusers were extracted from the records of the Department of Forensic Medicine at the All India Institute of Medical Sciences, New Delhi. These records contained information obtained from the scene of the suicide, from interviews with relatives of the deceased, and from forensic toxicological analyses at two laboratories.

RESULTS

There were 27 (8%) cases of prescription drug suicide in non-abusers out of 338 cases of suicidal poisoning. The mean age of this sample was 26 years. The sample was 74% male. Nearly half of the cases (44%) were students. A combination of dextropropoxyphene with dicyclomine, with or without paracetamol, was used by 41% of cases. Overdose was achieved through the ingestion of 10-40 (median, 30) tablets or by the injection of 2-3 (median, 2) vials of medication. In 52% of cases, it appeared that the drugs had been procured over the counter.

CONCLUSIONS

It is reassuring that the absolute number of prescription drug suicides in non-abusers was small; the findings, however, are important because they could serve as a baseline for assessing time trends in future studies. For the present, we suggest that prescription drugs of potential abuse, especially those containing opioids and antispasmodics, should be prescribed and dispensed judiciously, especially to youth.

Irritable bowel syndrome: The evolution of multi-dimensional looking and multidisciplinary treatments

Irritable bowel syndrome (IBS) is common in the society. Among the putative pathogeneses, gut dysmotility results in pain and disturbed defecation. The latter is probably caused by the effect of abnormal gut water secretion. The interaction between abnormal gas accumulation, abdominal pain and bloating remains controversial. Visceral hypersensitivity and its modification along with the central transmission are the characteristics of IBS patients. The identification of biologic markers based on genetic polymorphisms is undetermined. Imbalanced gut microbiota may alter epithelial permeability to activate nociceptive sensory pathways which in turn lead to IBS. Certain food constituents may exacerbate bowel symptoms. The impact of adult and childhood abuses on IBS is underestimated. Using the concept of biopsychosocial dysfunction can integrate multidimensional pathogeneses. Antispasmodics plus stool consistency modifiers to treat the major symptoms and defecation are the first-line drug treatment. New drugs targeting receptors governing bowel motility, sensation and secretion can be considered, but clinicians must be aware of their potential serious side effects. Psychiatric drugs and modalities may be the final options for treating intractable subjects. Probiotics of multi-species preparations are safe and worth to be considered for the treatment. Antibiotics are promising but their long-term safety and effectiveness are unknown. Diet therapy including exclusion of certain food constituents is an economic measure. Using relatively safe complementary and alternative medicines (CAMs) may be optional to those patients who failed classical treatment. In conclusion, IBS is a heterogeneous disorder with multidimensional pathogeneses. Personalized medicines with multidisciplinary approaches using different classes of drugs, psychiatric measures, probiotics and antibiotics, dietary therapy, and finally CAMs, can be considered.