How do you spell relief for irritable bowel syndrome?
The Journal of Family Practice. 2008 February;57(2):100-108
February 1, 2008|Family Medicine
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Many treatment options lack strong evidence for their efficacy. Others have proven efficacy, but restricted use.
TABLE 2
These red flags and alarm symptoms should prompt further evaluation1,22,23
| PATIENT PRESENTATION |
| Age of onset >50 years Fever Nocturnal symptoms Blood in stools Anemia Weight loss >10% body weight Profuse or large volume of diarrhea Family history of inflammatory bowel disease or cancer |
| PHYSICAL EXAMINATION |
| Fever Fecal blood organomegaly Jaundice Positive physical findings such as peritoneal signs or focal abdominal tenderness |
Many treatment options, limited quality research
Few pharmaceutical compounds have been tested and proven effective in reproducible, high-quality, double-blind, placebo-controlled trials (TABLE 3).1,29-43 In addition, no alternative or complementary therapies have been proven in quality clinical trials to date (TABLE 4).39,44-46,50 Behavioral therapy has shown benefit, but lacks double-blind, placebo-controlled trial data required for a level A strength of recommendation (SOR) (TABLE 5).1,47,48 That said, there are various options that can help patients with IBS—specifically, those who have IBS with diarrhea, IBS with constipation, IBS with mixed bowel habit (where stools are reported as >25% hard or lumpy and >25% loose or watery1), or IBS with unspecified bowel habit.
TABLE 3
Pharmacologic options for IBS
| TREATMENT | CLINICAL EFFICACY* | SOR | COMMENTS |
|---|---|---|---|
| 5-HT3 receptor antagonist (alosetron)1,29,30 | IBS with diarrhea Global symptom relief, improvement in individual symptom measures, improved quality of life scores (NNT=7) | A | Drug available through limited access program |
| 5-HT4 receptor agonist (tegaserod)1,29,31 | IBS with constipation Global symptom relief, improvement in individual symptom measures, improved quality of life scores (NNT=14) | A | Marketing suspended on March 30, 2007;32 limited temporary access program makes individual symptom measures, improved drug available through FDA33 |
| Antibiotics (neomycin, rifaximin)34 | IBS/IBS with diarrhea Global symptom relief, improvement in bowel habits for IBS with diarrhea | B | May benefit a subset of IBS patients with small intestinal bacterial overgrowth. Other research groups have not replicated results to date in IBS patients. Rifaximin produces most durable results |
| Anticholinergics/Calcium channel blockers (hyoscyamine, dicyclomine, mebeverine, otilonium bromide, pinaverium bromide)35,36 | IBS Improvement in abdominal pain (NNT=4–15) | B | Long history of use in IBS patients; however, little credible evidence to support use or efficacy in relief of global IBS symptoms. Best evidence with calcium channel blockers and anticholinergics comes with agents not available in US: mebeverine, otilonium bromide, and pinaverium bromide |
| Bulking agents (ispaghula husk, polycarbophil)35,36 | IBS with constipation Improvement in bowel habits (NNT=2.2–3.5) | B | Improvement in bowel habits, but no significant difference vs placebo for other measures; may aggravate bloating and abdominal pain |
| Chloride-Channel receptor agonist, ClC2 (lubiprostone)37 | IBS with constipation Global symptom relief, improvement in individual symptom measures | B | Indicated for chronic constipation; pending FDA review of data for IBS with constipation indication |
| Loperamide1,38 | IBS with diarrhea Improvement in bowel habits (NNT=3–5) | B | Reduction in diarrhea, but no better than placebo in global relief of symptoms or pain |
| Osmotic Laxatives (polyethylene glycol, lactulose)1,39,40 | IBS with constipation Improvement in bowel habits (NNT=2–4) | B | Lacks randomized controlled trials in IBS. Improvement in bowel habits, but no significant difference vs placebo for other measures; may aggravate bloating and abdominal pain |
| SSRIs (citalopram, fluoxetine, paroxetine)35,41-43 | IBS/IBS with constipation Improvement in abdominal pain and quality of life scores (NNT=3–6) | B | Limited and inconclusive data; diarrhea common side effect on beginning therapy. Start with low dose, increase as needed; may be useful for IBS with constipation patients, but it’s uncertain if effect is on the enteric nervous system, central nervous system, or both |
| Tricyclic antidepressants (TCAs)35,41 | IBS/IBS with diarrhea Improvement in abdominal pain (NNT=3) | B | May increase constipation, does not produce global relief of symptoms, and patients experience poor tolerability (effect on gut function occurs predominantly with lower doses). Hypothesized to modify central- enteric nervous system communication |
| * We did not calculate NNT endpoints on studies of poor quality, those with a small number of patients, or in cases where results were not reproducible in a consistent fashion or were not published in manuscript form. | |||
| IBS, irritable bowel syndrome; SOR, strength of recommendation; NNT, number needed to treat; FDA, Food and Drug Administration; SSRI, selective serotonin reuptake inhibitor. | |||
TABLE 4
Complementary and alternative therapies for IBS
| TREATMENT | CLINICAL EFFICACY | SOR | COMMENTS |
|---|---|---|---|
| Acupuncture44 | No proven benefit | C | Poor-quality trial with heterogeneous interventions, controls, and outcomes measured |
| Chinese herbal therapy45 | Reported improvement in global symptoms and pain | C | Very few high-quality clinical trials. Mixtures vary, content unknown, and some mixtures can be toxic. Unknown which herbs might produce benefit |
| Herbal Therapy (Curcuma xanthorrhiza, Fumaria officinalis)45 | No proven benefit | C | Tested in quality clinical trial; no efficacy over placebo |
| Peppermint Oil (colpermin)39, 50 | Improvement in abdominal pain | B | Lacks data on global symptom improvement; mechanism of action is similar to that of calcium channel blockers |
| Probiotics (Bifidobacterium infantis, Lactobacillus, B animalis)46 | Global symptom relief and improvement in individual symptom measures | B | Preliminary trials encouraging, but differences in trial design, probiotic dose, strain, as well as unpredictable symptom response, has not yielded consistent evidence. No quality of life improvement seen in early studies |
| SOR, strength of recommendation | |||
TABLE 5
Hypnotherapy and psychotherapy for IBS
