IBS: The evidence for conventional pharmacological treatment

IBS is one of the most common disorders seen in primary care and gastroenterology specialty practice. Conventional medicine approaches consist of combinations of diet advise, psychological, and drug therapies.

Current conventional medicine guidelines make a number of recommendations for treatment [i],[ii]. However most of these are consensus-based and have inadequate clinical evidence for a strong recommendation. The summary of US guidelines notes, “Despite the large number of published studies, in most cases our recommendations are weak because either (1) the quality of the available data and/or (2) the balance of risks and benefits for a particular therapy do not overwhelmingly support its use.”

Pharmacotherapy* is directed toward modifying the symptoms of IBS that ranges from IBS-C which is constipation-dominant, to IBS-D – diarrhea dominant, and IBS-M which has both. Among the suggested or recommended pharmacological interventions are antispasmodics, antidepressants, and eluxadoline (IBS-D), lubiprostone (IBS-C), and linaclotide (IBS-C).

  • Antidepressants: A 2011 Cochrane review concluded that SSRIs and tri-cyclic antidepressants have “good” evidence of effectiveness, but effectiveness may be depend on “the individual patient.”[iii]
  • Antispasmodics: Found by this same review to be effective in some patients.  About 3-7 patients need to be treated in order to produce 1 successful outcome (NNT).
  • Bulking agents: Cochrane found no evidence to support bulking agents (soluble and insoluble fiber.)
  • Psychological therapies: A recent review (2019) suggests that while the evidenced is of limited quality, psychological therapies (cognitive behavioral therapy (CBT), relaxation therapy, multi-component psychological therapy, hypnotherapy, and dynamic psychotherapy) appear to be helpful.

The website www.drugs.com lists 79 medications (Rx, OTC, off-label) used to treat IBS. Over the counter medications are used frequently. OTC bismuth and loperamide (Kayopectate, Pepto-Bismol, Imodum)have been shown to provide relief of diarrhea but have no effect on other IBS symptoms. IBS-C can be treated with a variety of drugs intended to get things moving when constipation strikes. Dietary fiber sources, osmotic laxitives, stool softeners, and stimulant laxatives have evidence of varying degrees of effectiveness and individual risk profiles for adverse events.

Our final installment covering IBS in April will look at the evidence for integrative healthcare treatment options for patients dealing with Irritable Bowel Syndrome.

[i]Canadian Assoc. of Gastroenterology. (Accessed 4/2/19 at https://www.cag-acg.org/images/publications/CAG_CPG_for_Management_of_IBS_JCAG_Jan2019.pdf)

[ii] Weinberg, David S. et al. American Gastroenterological Association Institute Guideline on the Pharmacological Management of Irritable Bowel Syndrome. Gastroenterology , Volume 147 , Issue 5 , 1146 – 1148

[iii] Ruepert  L, Quartero  AO, de Wit  NJ, van der Heijden  GJ, Rubin  G, Muris  JWM. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD003460. DOI: 10.1002/14651858.CD003460.pub3.

IBS: The gut-brain-microbiome connections

For over 4000 years, the system of classical traditional Chinese medicine described fundamental connections of the bowel and the “lung.’  This linkage guided acupuncture and Chinese medicine practitioners ever since. Hippocrates is said to have observed, “bad digestion is at the root of all evil…death sits in the bowels.” In Western medicine the digestive system has been thought of primarily as a tube through which food passes, nutrients are extracted, and waste eliminated.

Patients are often painfully aware of the symptoms of IBS and how the intestinal tract interacts with the brain. People with IBS also tend to exhibit signs of stress, anxiety, and depression. IBS patients have a greater potential for thoughts of suicide,[i]  In the past IBS was often dismissed as “functional” or psychosomatic in origin.

Current understanding of digestion has modeled a multi-directional communication system termed “the gut-brain axis” (GBA). Put something in your mouth and the entire system is affected.Nerve connections within the various regions of the gut and between the gut and the central nervous system are beginning to unravel this complexity.

Further understanding expands the gut-brain axis to include the microbes that inhabit the alimentary canal form one end to the other. Not only are the gut and brain tightly interconnected, but the presence of gut flora influences this system such that now the GBA is extended to the gut-brain-microbiome axis (GBMA). A 2017 review[ii] provides a good summary of current concepts of the complex interactions of the GBMA.

The average adult human GI tract hosts up to 1014 organisms, over 2 pounds worth in total.  This is much larger that the number of human cells in the body.  The genetic information encoded in the microbiome is more than 100 time that in humans.  This concept is a paradigm shift in the understanding of digestion and health and brings to light ideas that originated millennia ago.

Accounting for the microbiota in health and disease provides a clinical rationale for treatments.  For example, manipulating the micro-organisms in the GI tract through the use of pre- and probiotics has been shown clinically to be effective.  With the GBMA model, we know why and how this treatment works.

Next time we’ll look at the evidence supporting pharmacologic interventions for IBS.

[i] Miller, Vivien et al. Suicidal ideation in patients with irritable bowel syndrome Clinical Gastroenterology and Hepatology , Volume 2 , Issue 12 , 1064 – 1068

[ii] Dinan, Timothy G. et al. The Microbiome-Gut-Brain Axis in Health and Disease Gastroenterology Clinics , Volume 46 , Issue 1 , 77 – 89

IBS: A condition without a cause

Irritable Bowel Syndrome (IBS) is identified clinically as a “syndrome” and as such it is defined by a collection of symptoms rather than a definite patho-anatomical disease  entity with pathological markers. Various clinical (and patient experience) features of IBS have attracted their own names: irritable colon, spastic colon, nervous colon, colitis, mucous colitis.   The cause of IBS has long been considered to be “unknown.”  Early theories of IBS implicated psychological problems, psychosomatic or other mental disorders.

April is Irritable Bowel Awareness Month in the US. The International Federation for Functional Gastrointestinal Disorders (IFFGD) is a non-profit organization that involves collaboration among patients, the public, health care providers, researchers, and health care policy makers to understand the impacts of IBS and to support research into this troubling disorder. In recognition of this important condition, our blog posts in April will focus on IBS and how integrative health care can improve health and quality of life in persons afflicted with IBS.

Recently however, expanded scientific understanding of the human digestive system has shed light on the complexity of interactions among the gut, the nervous system and the micro-organisms that populate the human gut and can cause disordered function. The outcomes of this disordered function causes the wide variety of patient experienced symptoms: pain, constipation, diarrhea, gas, bloating, etc.

Symptoms of IBS are well recognized and typically show waxing and waning of various combinations of abdominal pain, cramping or bloating typically relieved by passing a bowel movement, excess gas, diarrhea, constipation (sometimes both), and mucus in the stool. Sets of clinical criteria have been formalized to more consistently define IBS. The Manning Criteria developed in 1978 for a diagnosis of IBS include:

  • Sensation of incomplete evacuation.
  • Pain relieved with defecation.
  • More frequent stools at the onset of pain.
  • Looser stools at the onset of pain.
  • Visible abdominal distention.
  • Passage of mucus.

More recently the Rome IV criteria considers IBS of 4 types: 1) IBS with constipation (IBS-C), 2) IBS with diarrhea (IBS-D), 3) mixed IBS, and unclassified IBS.[i],[ii]

Irritable bowel syndrome (IBS) affects an estimated10-15% of the US population. IBS is second only to upper respiratory illness as a cause of absenteeism from work and school. Among those who report IBS symptoms, and 40% or more have not had a formal diagnosis or medical treatment.[iii]  People who suffer with IBS experience significant disruption in their lives missing work and leisure activity, modifying daily plans around trips to the bathroom, and putting up with abdominal pain, gas, bloating and the anxiety of never knowing when these symptoms may strike.

Despite the prevalence of IBS and the high social costs of IBS (estimated at ~$21 billion in medical bills and lost productivity), the condition continues to be incompletely understood and treatments are not reliably effective.

Our next post will explore recent developments in the understanding of the human gut in IBS.

[i] Schmulson MJ, Drossman DA. What is new in Rome IV. Neurogastroenterol Motil. 2017
[ii] 1 Lacy BE, et al. Bowel Disorders. Gastroenterology. 2016;150:1393-1407; Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders.
[iii] Sayuk GS, et al. Am J Gastroenterol. January 2017.

Acute Flaccid Myelitis in Pediatric Patients

A December 2018 article by Roy Benaroch, MD, published by KevinMD.com, and blogged on ‘Pediatric Insider’, describes physical profiles defining this Acute Flaccid Myelitis (AFM). You may have seen reports of a ‘polio-like’ illness causing pediatric paralysis. 80 cases were reported in the USA in 2018. Although the cause is currently unknown, several viral infections have been found in AFM children.

Here’s what to watch for:

  • Sudden (defined as beginning in the last few hours or days) illness causing extremity paralysis in singular or multiple limbs.
  • Typical presentation: Fever, runny nose, cough, vomiting or diarrhea 1-2 weeks prior to AFM symptoms.
  • Lesser seen symptoms: Stiff neck, headache, pain in limbs, eyelid or facial droop, difficulty swallowing, speaking or a hoarse or weak voice.
  • Near complete paralysis to varying degrees of paralysis follows two weeks after viral infection.
  • Affected body parts are weak and floppy.
  • The disease starts in the spinal cord and may mimic severe trauma.
  • History is key in diagnosis.
  • MRI shows distinctive changes of inflammation, confirming diagnosis.
  • Most cases appear in late summer and early fall; August through October.
  • Average age of occurrence: 4-6 years.
  • Most commonly, no viral infection is found.
  • Investigation of specific viral causes includes but is not yet definitive: enterovirus D68, West Nile Virus, Japanese Encephalitis viruses, herpes viruses and adenoviruses.

Children with this profile need hospitalization. Neurologists and infectious disease specialists direct care to include IV immunoglobulin, steroids, and plasmapheresis. Some children recover quickly while others may need long-term care. This article focuses on how to prevent viral infections by educating parents and children.

NCCIH and CARBON Program – 2015-2020 Research

The NCCIH is sponsoring the Centers for Advancing Research on Botanical and Natural Products (CARBON) Program. Research scheduled for 2015-2020 includes:

The goal of this center in it’s second five-year research cycle is to delineate molecular mechanisms by which botanical oils prevent or impact disease with a particular focus on immunity and inflammation. The study will study different populations to determine where botanical lipids are most likely to be effective. For more information on this program visit https://ods.od.nih.gov/Research/Dietary_Supplement_Research_Centers.aspx

Myofascial Massage for Chronic Pain After Breast Surgery

A 2018 research article published by the International Journal of Therapeutic Massage & Bodywork highlighted massage to improve upper extremity mobility and decrease pain following breast cancer surgery. The study included 21 female subjects at 3-18 months post-surgery, receiving 16, 30-minute massage sessions, over 8 weeks, using Swedish technique on the entire body. Control subjects received the same treatment, but avoided any massage of the affected breast, shoulder and chest. Outcome measures included pain scales and quality of life questions. Compared to the control group, the subjects with site specific treatment had more favorable outcomes. However, all subjects reported reduced self-reported pain and decreased feelings of ‘downheartedness’. The site specific group had better outcomes with decreased pain and improved mobility.


Medical Doctors and Chiropractors Top Choices for Neck and Back Pain

According to a recent Gallup-Palmer College poll, patients with neck and back pain in the US who saw healthcare professionals in the last 12 months were most likely to seek care from a medical doctor or a chiropractor.  Approximately one-third saw a massage therapist or physical therapist.  Acupuncturists were also on this list of top choices for spine care.

Did you see any of the following healthcare professionals for your neck or back pain in the last 12 months? (asked of those who saw a healthcare professional for neck or back pain in the past 12 months)

Provider Type Yes
Medical Doctor 62%
Chiropractor 53%
Massage Therapist 34%
Physical Therapist 34%
Physician’s Assistant 26%
Nurse Practitioner 22%
Surgeon who can operate on spine 22%
Doctor of osteopathic medicine 15%
Acupuncturist 9%
Sample sizes: 988-1,157
Gallup-Palmer College, March 12-April 10, 2018

For more, go to: https://news.gallup.com/poll/243302/medical-doctors-chiropractors-top-choices-spine-care.aspx

Positive Thoughts Towards Others Improves Healthy Behavior

According to a 2018 study with 220 subjects, when patients adopt a regular habit of focusing on ‘others well-being’ they are more likely to participate in exercise and other healthy behaviors affecting positive lifestyle changes. “Self- Transcendence” refers to a shift in mindset from focusing on self-interests to the well-being of others. Subjects were asked to focus on loved ones or making positive wishes for others. This activity of self-transcendence upregulated activity in a region of the ventromedial prefrontal cortex. This area of the brain is responsible for reward processing. Providers would do well encouraging patients to focus away from their conditions of chronic pain and illness in a way that encompasses a bigger picture. Helping patients see the need to do so is a form of Pain Neuroscience Education (PNE). Explanations that include basic neuroscience education as it relates to mental health are within the scope of chiropractors, naturopathic physicians and acupuncturists, as long as the provider does NOT introduce discussion of case-specific patient mental health conditions. Discussion of specific conditions are in the venue of mental health.


Study Links Mindfulness to Brain Changes and Pain Sensitivity

People who are more naturally mindful (paying attention to the present moment without over-reacting to it), differ among individuals. There is evidence showing mindful people tend to have less pain. A study of 76 healthy people who had no experience with meditation completed a Frieburg Mindfulness Inventory, evaluating innate mindfulness. Subjects with a higher innate mindfulness score, reported less pain to a thermal probe delivering a series of brief, uncomfortable heat stimuli to the lower leg. In addition, an MRI scanner of their brain during testing demonstrated changes in blood flow  associated with greater deactivation of a brain region extending from the precuneus to the posterior cingulate cortex. This part of the brain is involved in attention and subjective emotional responses to sensation. It plays a role in how one reacts to experiences. This is another study supporting Pain Neuroscience Education (PNE) principles. Teaching patients about the neuroscience of pain, and how to change brain perception by participating in meditation, positive thinking or helping others, diverts and changes the way a human perceives  acute and/or chronic pain.


Integrative Cancer Care Options: In Depth

NIH and The National Center for Complementary and Integrative Health have produced a collection of research and facts for integrative approaches and treatments surrounding cancer. The research focuses on patient safety, outcomes and options to reduce symptoms in this patient population. Cautions are given to help providers understand scope limits and best practice recommendations when treating cancer patients. Adding some of the suggested integrative treatments is shown to reduce anxiety, pain, nausea and more.