Today, the American College of Gastroenterology (ACG) published a new systematic review of evidence about the management of irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC) to update earlier reviews from 2009 and 2005 as a supplement to the August 2014 issue of The American Journal of Gastroenterology. This analysis will allow physicians to better care for patients with IBS and CIC, and features new information for clinicians to consider when making recommendations about diet, probiotics, antibiotics and antidepressants for IBS, as well as the use of fiber, laxatives, and recently developed drugs—prucalopride, lubiprostone and linaclotide for managing constipation. This review also summarizes information about the effectiveness of other therapies, such as alosetron, lubiprostone and linaclotide, in treatment of IBS.
IBS and CIC (also referred to as functional constipation) are two of the most common functional gastrointestinal disorders worldwide, impacting anywhere from 5 to 15 percent of the global population. These conditions affect more than 30 million Americans and are among the most common gastrointestinal disorders treated by physicians. Although there has been an increase in the number of scientific studies of these conditions, they vary in quality, making it difficult for physicians to sort out the best approaches for management.
In general, treatments for IBS are directed towards the patient’s predominant symptoms. With a wide variety of available therapies, many of which improve individual IBS symptoms, only a small number of therapies have been shown to be of benefit for global symptoms of IBS.
“In order to evaluate the rapidly expanding research about IBS and CIC and to assess the evidence of efficacy of new IBS and constipation drugs, ACG sponsored an independent, systematic review, and all available studies were reviewed by the ACG Functional Bowel Disorders Task Force after a careful and systematic search of the literature in order to update the recommendations,” explained Eamonn M.M. Quigley, MD, FACG, who chaired the expert task force. “Studies meeting pre-specified criteria that were selected to minimize bias were examined in detail and summarized. When possible, results were combined by a formal meta-analysis to improve the reliability of conclusions.”
The quality of the evidence was graded by standard criteria and recommendations were developed based on the quality of the evidence and additional factors such as risk, cost and acceptability to patients.
The College’s new recommendations include updated information and expert assessments of traditional therapies for IBS and CIC, as well as a range of new treatment approaches, including evidence on diet, probiotics; the non-absorbable antibiotic rifaximin; antidepressants; antispasmodics and peppermint oil; fiber, bulking agents and laxatives; antidiarrheals, including loperamide; the 5-HT3 receptor antagonist alosetron; the 5-HT4 (serotonin) receptor agonist tegaserod; the chloride channel activator lubiprostone; psychological therapies such as hypnotherapy and biofeedback; herbal preparations; and acupuncture.
Highlights of ACG’s New Recommendations on IBS Therapies • Special elimination diets may be effective, but existing evidence is weak.• Fiber may be helpful in relieving IBS symptoms; there is better evidence in support of an effect of psyllium than of bran for IBS.• Prebiotics and synbiotics have insufficient evidence of effect in IBS.• Probiotics improve global symptoms, bloating and flatulence in IBS.• Rifaxamin, a poorly absorbed antibiotic, has moderate evidence in support of effectiveness in IBS with diarrhea.• Linaclotide and lubiprostone have strong recommendations for IBS with constipation.• There is better evidence than in the past to support the use of antidepressants and psychological therapies in IBS.Highlights of ACG’s New Recommendations on CIC Therapies • Fiber supplements are given a strong recommendation for use in CIC.• Laxatives—including polyethylene glycol (PEG), lactulose, sodium picosulfate and bisacodyl—have strong recommendations for the treatment of CIC.• Prucalopride, lubiprostone and linaclotide have been given strong recommendations for treatment of CIC.
“This new meta-analysis of the literature on the management of IBS and chronic idiopathic constipation offers physicians scientifically-based guidance to make clinical decisions about these conditions based on a thorough assessment of the evidence,” said Lawrence R. Schiller, MD, FACG, who is also a member of the ACG Functional Bowel Disorders Task Force. “However, it is important that patients talk with their doctors about their treatment options, as there is no one-size-fits-all approach to managing IBS or chronic constipation. It’s also vital that patients not be embarrassed to talk openly about their symptoms with their doctor in order to collaboratively determine the best treatment plan for their individual situation.”
About IBSFor the clinical gastroenterologist, IBS is one of the most commonly seen digestive problems. IBS is characterized by abdominal discomfort associated with altered bowel function; structural and biochemical abnormalities are absent. The pathophysiology of IBS is multi-factorial. Individual symptoms have limited accuracy for diagnosing IBS, and the disorder is considered as a symptom complex.
About CICConstipation is a symptom-based disorder defined as unsatisfactory defecation, and is characterized by infrequent stools, difficult stool passage or both. Difficult stool passage includes straining, a sense of difficulty passing stool, incomplete evacuation, hard/lumpy stools, prolonged time to pass stool, or need for manual maneuvers to pass stool. CIC is defined as the presence of these symptoms for at least 3 months.
ACG Expert Task Force on the Management of Functional Bowel Disorders • Chair, Eamonn M.M. Quigley, MD, FRCP, FACG, Houston, Methodist Hospital and Weill Cornell Medical College• Brian E. Lacy, MD, PhD, FACG, Dartmouth-Hitchcock Medical Center• Anthony J. Lembo, MD, Harvard Medical School, Beth Israel Deaconess Medical Center• Paul Moayyedi, BSc, MB, ChB, PhD, MPH, FRCP (London), FRCPC, FACG*, McMaster University Medical Centre• Yuri Saito, MD, MPH, Mayo Clinic, Rochester• Lawrence R. Schiller, MD, FACG, Baylor University Medical Center• Edy E. Soffer, MD, FACG, Keck School of Medicine, University of Southern California• Brennan M. R. Spiegel, MD, MSHS, UCLA School of Medicine
*Dr. Moayyedi conducted the systematic reviews with support from Alexander C. Ford, MD, ChB, MD, FRCP, and carried out the technical analyses of the data independent of the Task Force.
About the American College of GastroenterologyFounded in 1932, the American College of Gastroenterology (ACG) is an organization with an international membership of more than 12,000 individuals from 80 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high quality, evidence-based, and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment. www.gi.orgAbout The American Journal of GastroenterologyThe American Journal of Gastroenterology is published on behalf of the American College of Gastroenterology by Nature Publishing Group. As the leading clinical journal covering gastroenterology and hepatology, The American Journal of Gastroenterology provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, AJG devotes itself to publishing timely medical research in gastroenterology and hepatology. The Co-Editors-in-Chief are William D. Chey, MD, AGAF, FACG, FACP of the University of Michigan and Paul Moayyedi, BSc, MB ChB, PhD, MPH, FRCP, FRCPC, FACG of McMaster University.
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