Irritable bowel syndrome: Minimize testing, let symptoms guide treatment

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Applied Evidence

Irritable bowel syndrome: Minimize testing, let symptoms guide treatment

J Fam Pract. 2003 December;52(12):942-950

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References

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26. Jones BW, Moore DJ, Robinson SM, Song F. A systematic review of tegaserod for the treatment of irritable bowel syndrome. J Clin Pharm Therapeutics 2002;27:343-352.

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28. Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther 2001;15:1655-1666.

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TABLE 4
Complementary and alternative treatments for irritable bowel syndrome

Treatment	Efficacy	SOR	Outcomes measured	Comments
Neomycin ²⁰	Treatment for 1 week improved symptoms of abdominal pain, diarrhea, and constipation	A	Abdominal pain, diarrhea, or constipation	Studies measuring global symptom improvement lacking
Peppermint oil ^31,4849	Some demonstrated improvement in abdominal pain	B	Individual IBS symptoms	Studies measuring global symptom improvement lacking
Guar gum ⁴⁴	Improved abdominal pain and bowel alterations	B	Study compared fiber to guar gum–equal affect on abdominal pain. Gum was better toleratEd	No placebo-controlled trials
Probiotics⁴⁸ (lactobacillus)	Improvement of abdominal pain and flatulence	C	Abdominal pain, flatulence	Two studies with small numbers
Elimination diets ⁴⁸	Improvement of diarrhea	C	Diarrhea	Milk, wheat, eggs eliminated; 15%-71% improvement of diarrhea
Lactose and fructose avoidance ⁴⁸	Conflicting evidence results	D		No controlled studies available
Pancreatic enzymes ⁴⁸	No evidence	D		Evidence lacking
Ginger ⁴⁸	No evidence	D		No studies

Medications

Strength of recommendation: A. The recently approved 5HT₄ receptor agonist tegaserod (Zelnorm) is more effective than placebo at relieving global symptoms in women with constipation (number needed to treat [NNT]=3.9-17).^26-30 Diarrhea can be a serious side effect.

The 5HT₃ receptor antagonist alosetron (Lotronex) is more effective than placebo at relieving global IBS symptoms in women with diarrhea (NNT=2.5-8.3).^31-35 Severe constipation can be an adverse effect. The prescribing of alosetron is currently restricted to physicians who participate in the manufacturer’s risk management program.

In addition to these serotoninergic agents, others in this class are being developed and undergoing clinical trials. The knowledge being gained about 5HT receptors may revolutionize the care of patients with IBS.

Strength of recommendation: B. Tricyclic antidepressants are no more effective than placebo at relieving global IBS symptoms, but they do decrease abdominal pain (NNT=3.2-5).^36-39

Loperamide is no more effective than placebo at relieving IBS global symptoms, but it may be used to treat diarrhea (NNT=2.3-5).^31,40-42

Bulking agents (such as calcium polycarbophil or psyllium) are no more effective than placebo at relieving IBS global symptoms, but they may decrease constipation (NNT=2.2-8.6).^31,36,43-47

Peppermint oil may be helpful for abdominal pain, but global symptom reduction has not been demonstrated.^31,48-49 Only a few studies have looked at the use of antispasmodic agents for IBS. They are of poor quality and used small numbers with no placebo controls.^23,31,36,43

Strength of recommendation: C. There are limited studies evaluating the selective serotonin reuptake inhibitors (SSRIs) fluoxetine and paroxetine. Paroxetine was shown in 1 study to improve quality of life.⁵⁰ Fluoxetine reduced abdominal pain, but did not improve quality of life.⁵¹

Behavioral and complementary/alternative therapies

Relaxation therapy, hypnotherapy, and cognitive therapy are effective at relieving individual IBS symptoms, but have not been shown to reduce global IBS symptoms (SOR: B).^52-57 Other alternative therapies (eg, guar gum⁴⁴ [SOR: B], ginger⁴⁸ [SOR: B], and pancreatic enzymes⁴⁸ [SOR: C]) have been studied, but high-quality studies considering global improvement have not been published.

Methods used to develop this article

The position statement of the American College of Gastroenterology on the management of IBS²³ and Brandt’s systematic review of this subject²⁴ were the starting points for this review. The majority of the references from these sources were reviewed and a Medline search was completed to identify new evidence. The Oxford Centre for Evidence-Based Medicine grades of recommendations were applied to this evidence, a care algorithm was created, summary tables were developed, and numbers needed to treat were calculated.

Promote self-awareness

Quality-of-life assessment should be done routinely in the care of IBS patients. Provide support, empathy, and basic behavior modification tools. Educate patients and their families on the theoretical biochemical basis of this illness, and help them connect symptoms with stressors, to facilitate lifestyle modification.

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: keholtenmd@cmhregional.com.