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IBS-C and IBS-D:Tailoring Non-pharmacologic and Pharmacologic Interventions
Gregory Sayuk, MD, MPHAssociate Professor of Medicine and PsychiatryWashington University in St Louis
Disclosures• The following are my disclosures. Potential conflicts
of interest have been resolved.
Research Support / Grants None
Stock/Equity None
Consulting Synergy, Allergan/Ironwood
Speakers Bureau / Honoraria Synergy,Allergan/Ironwood, Salix
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IBS Direct and Indirect CostsHigh economic and social burdens
– Direct costs: medications, testing• Up to 30 million adults affected in U.S.• 1.5 x more office visits (25% GI of practice)
– Indirect costs• Miss work/school (avg 2.4 days/month)• 13.7 million days lost productivity/year• 60% report impairment at work due to symptoms
Dennison C et al.Pharmacoeconomics 2005. Bracco K et al. Am J Gastroenterol 2004. Agarwal N and Spiegel BMR. Gastroenterol Clin NA 2011. Chang L et al. AP&T 2004. Whitehead WE et al. J Am Geriat Soc 1989. Talley NJ. Rev Gastroenterol Disord 2004. Spiegel B et al. AP&T 2007.
– Lower health-related QOL– Psychological impact
• Higher depression/anxiety• Suicidality?
– More restricted physical/social activities
Recurrent abdominal pain, on average, ≥1 day per week in
the last 3 months, associated with ≥ 2 of the following:
• Related to defecation• Change in frequency of
stool
• Change in form(appearance) of stool
Defining and Characterizing IBS
Rome IV Criteria for IBS1IBS Subtypes Based on
Bristol Stool Forms2,3
Criteria should be fulfilled for the last 3 months with symptom
onset ≥ 6 months before diagnosis
IBS-C, irritable bowel syndrome with constipation; IBS-D, irritable bowel syndrome with diarrheal IBS-M, irritable bowel syndrome with mixed symptoms.1. Lacy BE et al. Gastroenterology. 2016;150:1393-1407; 2. Longstreth GF et al. Gastroenterology. 2006;130:1480-1491;3. O�Donnell LJD et al. BMJ. 1990;300:439-440.
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Conceptual Biopsychosocial Model of IBSInteraction of factors raise potential for multiple, diverse treatment options
Adapted from: Tornblom H and Drossman D. NGM 2015. See also: Perera TD et al Neuroscientist 2008 and Perera TD et al. J Neurosci 2007.
IBS SYMPTOMS
High
Low
PREDISPOSING FACTORS
Genetics Early trauma
Abuse
Environmental factors
MECHANISTIC FACTORS PERPETUATING FACTORS TREATMENT
Infection
SecretionGut Motility
Visceral hypersensitivity
Diet
Central hypersensitivity*
Diet/lifestyle
Anxiety/stress
Depression
Gut-centric therapy
Antibiotics/probiotics
Antidepressants/psychological
Exercise/yoga
Supportive
Bacterial overgrowth
* Co-morbid pain diagnoses are an important marker
Diet
IBS Treatment An evidence-based approach
Ford AC et al. Am J Gastroenterol 2018.
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IBS-C ManagementPharmacological options
STR
EN
GTH
OF
EV
IDE
NC
E
Hig
hLo
w
Ford AC, et al. ACG Monograph on Management of IBS. Am J Gastroenterol 2018. Weinberg DS et al. AGAI Guideline on Pharmacologic Management of IBS, Gastroenterol 2013.
Lubiprostone
Linaclotide
Antispasmodics/anticholinergics
RECOMMENDATION
Strong Weak
SSRI Antidepressants
Tricyclic antidepressants (TCAs)
Plecanatide
Polyethylene glycol (PEG)
IBS-D ManagementPharmacological options
ST
RE
NG
TH
OF
E
VID
EN
CE
Hig
hL
ow
Ford AC, et al. ACG Monograph on Management of IBS. Am J Gastroenterol 2018.
Loperamide
Antispasmodics/anticholinergics
RECOMMENDATION
Strong Weak
SSRI Antidepressants
Tricyclic antidepressants (TCAs)
Eluxadoline
Alosetron*
5-aminosalicylates
Rifaximin
* Available under FDA Risk Evaluation and Mitigation Strategy (REMS) Drug Safety Prog
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IBS PharmacotherapyRegulatory agencies mandate improvements in both
abdominal pain and bowel pattern
Linaclotide Linaclotide Linaclotide Linaclotide
Chey WD et al. Am J Gastroenterol 2012.Rao S et al. Am J Gastroenterol 2012.
Linaclotide in IBS-C Abdominal pain continues to improve over 26 weeks
P=.007 for Week 1P<.0001 for Weeks 2-26
Chan
ge in
Abd
omin
al P
ain
(%)
-60
-50
-40
-30
-20
-10
0
Trial WeekBL 2 4 6 8 10 12 14 16 18 20 22 24 26
Linaclotide 290 mcg Placebo
Chey WD et al. Am J Gastroenterol 2012.
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Antidepressants for Somatic Pain SyndromesMultiple controlled trials demonstrate benefit
1
O'Malley PG, et al. J Fam Pract. 1999;48:980-990.
Chronic Fatigue
Fibromyalgia
Functional GI
Idiopathic Pain
Headache
Tinnitus3.4 (2.6-4.3)
Odds ratio
Treatment Worse Treatment Better
AntidepressantsPutative effects on abdominal pain
• Central effects– Alterations in pain
perception (analgesia, antihyperalgesia)
– Modified attention to pain– Decreased stress
responses– Improvement of mood,
psychiatric disorders– Treatment of sleep
disturbances
• Peripheral effects– Alterations in visceral
afferent signaling– Effects on GI physiology
• Smooth muscle relaxation• Decreased secretion
Grover M and Drossman DA. Gastroenterol Clin N Am 2011.
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Meta-analysis: TCAs in IBS
Studyor sub-category
Treatmentn/N
Controln/N
RR (random)95% CI
Weight%
RR (random)95% CI
Tricyclic antidepressants
Heefner 1978Myren 1982Nigam 1984
Boerner 1988Bergmann 1991
Vij 1991Drossman 2003
Talley 2008Vahedi 2008
10/225/30
14/2116/425/19
14/2560/115
0/188/27
12/2210/3121/2119/4114/1620/2536/575/16
16/27
Subtotal (95% CI) 319 256 67.56 0.68 (0.56 to 0.83)
5.942.66
14.747.633.82
10.6716.770.335.02
0.83 (0.46 to 1.51)0.52 (0.20 to 1.33)0.67 (0.49 to 0.90)0.82 (0.50 to 1.36)0.30 (0.14 to 0.65)0.70 (0.47 to 1.04)0.83 (0.63 to 1.08)0.08 (0.00 to 1.36)0.50 (0.26 to 0.97)
Total events: 132 (treatment), 153 (control) Test for heterogeneity: X2 = 10.92, df=8, (P=.21), I2 = 26.9%
Test for overall effect: Z=3.86 (P=.0001)
Ford AC et al. Gut 2009 Mar;58(3):367-78.Ford AC et al. Am J Gastroenterol 2014.
Number needed-to-treat (NNT) using TCAs in IBS = 4
Higher doses (>50 mg) may be more effective in IBS-D
1. Ford AC et al. AJG 2014. 2. Lesbros-Pankoflickova et al. Aliment Pharmacol Ther 2004.
Side-effects from TCA treatment of FGIDs are common
0
10
20
30
40
50
% o
f sub
ject
s
Irritable bowelsyndrome
Functionaldyspepsia
SedationOther CNSAnticholinergic
Clouse RE et al. Dig Dis Sci 1994; Prakash C et al. Dig Dis Sci 1998.
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Tricyclic AntidepressantsReceptor affinity predicts side effects
Receptor Affinities*
* For acetylcholine, histamine, and a-adrenergic receptors
3o
amines Amitriptyline Imipramine Doxepin ++ - +++
Nortriptyline Desipramine2o
amines + - ++
Clouse RE and Lustman PJ. GUT 2006.
Recent Tricyclic Antidepressant Trials for IBS
Rajagopalan1998 Amitriptyline (25à75)
12-wk DB RCT
n=40+ + +
Drossman 2003 Desipramine(50à150)
12-wk MC CC RCT
n=216- NA +*
Morgan 2005 Amitriptyline (50) 4-wk RCT
n=19 + NA NA
Vahedi 2008 Amitriptyline (10) 8-wk DB RCT
n=50- + +
Bahar 2008 Amitriptyline (10-30) 13-wk DB RCT
n=33 (adolescent)+ - +
Abdul-Baki 2009 Imipramine (25) 12-wk RCT
n=56- + +
*Per protocol analysis NA = not assessed DB=double-blinded RCT=randomized controlled trial CC=comparator-controlled MC=multi-center study
Study DesignDrug (mg/day)Well-being
Global IBS symptoms
Abdominalpain relief
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Amitripyline for IBSTCAs effective at low doses
0
20
40
60
80
100
Intention to treat Per protocol
AMI 10 mg qHsPlacebo
8 week treatment period
** p<0.01 for eachNo significant difference in adverse events between groups
** **
Vahedi H et al. AP&T 2007.
Meta-analysis: SSRIs in IBS
Selective serotonin reuptake inhibitorsKuiken 2003Tabas 2004Vahedi 2005Tack 2006Talley 2008
Subtotal (95% CI) 113 117
9/1925/446/225/115/17
12/2136/4619/2211/125/16
5.8514.904.524.902.27
0.83 (0.45 to 1.51)0.73 (0.54 to 0.98)0.32 (0.16 to 0.64)0.50 (0.25 to 0.97)0.94 (0.33 to 2.65)
32.44 0.62 (0.45 to 0.87)
Total events: 50 treatments; 83 controlsTest for heterogeneity: X2 = 6.46, df = 4, (P=.17), I2 = 38.1%
Test for overall effect: Z = 2.74 (P=.006)
Fewer, smaller studies to date.
Number needed-to-treat (NNT) using SSRIs in IBS = 4Anecdotally, less effective than TCAs for abdominal pain.
Ford AC et al. Gut 2009.
Ford AC et al. Gut 2009 Mar;58(3):367-78.Ford AC et al. Am J Gastroenterol 2014.
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Antidepressants in FGIDOverview of options
TCAs SSRIs SNRIsAgents Amitriptyline,Desipramine
NortriptylineFluoxetine, Sertraline, Paroxetine, Citalopram
Duloxetine, VenlafaxineDesvenlafaxine, Milnacipran
Dose range 10-200 mg (start low, go slow!)
10-100 mg 30-90 mg (duloxetine)75-225 mg (venlafaxine)
Adverse effects SedationConstipationDry mouth/eyesWeight gainHypotensionSexual dysfunction
InsomniaDiarrheaNight sweatsWeight lossAgitationSexual dysfunction
NauseaAgitationDizzinessFatigueLiver dysfunctionConstipation
Time to action Few days to 2 weeks (low doses)2-6 weeks (high doses)
3-6 weeks 3-6 weeks
Efficacy Good for IBS and FD Good (IBS>FD); consider with + mood disorder
Limited studies (IBS>FD?)Good global response
Dose adjustments
Common Minimal Common
TCA=tricyclic antidepressant; SSRI=selective serotonin reuptake inhibitor; SNRI=serotonin-norepinephrine reuptake inhibitor
Grover M, Drossman DA. Gastrointest Endoscopy Clin N Am. 2009;19:151-170.
Buspirone, a 5-HT1D agonistImprovement in dyspeptic symptoms
Rx: Buspirone 10 mg tid for 2 weeks
àPain benefit associated with changes in gastric accommodation Tack J et al. CGH 2011.
2
4
6
8
10
12
14
0
PLACEBO BUSPIRONE
Baseline BaselinePost-Rx Post-Rx
**
Dysp
epsi
a se
verit
y sc
ore
(DSS
)
** p<0.005 vs PBO
6
8
10
12
14 PLACEBO BUSPIRONEAnecdotally, excellent adjunct with TCAs for abdominal pain
Few drug interactions, very well tolerated
Titrate slowly (start 5 mg qd for 1 wk, then 5-7.5 mg bid)
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IBS PharmacotherapyRemember when?
IBS PharmacotherapyTegaserod for IBS with constipation
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Tegaserod for IBS with constipation“Not all smiles”
• March 30, 2007, the Food and Drug Administration (FDA) “discontinued marketing” of tegaserod“for safety reasons.”
• Retrospective review of 29 premarketing trials involving 11,614 tegaserod-treated subjects and 7,031 subjects who were treated with placebo found a 10-fold increase in the RR of significant pooled cardiovascular events:
• 0.1% in tegaserod-treated patients vs. with 0.01% in placebo • Number needed to harm (NNH) was 1,111
• FDA: because tegaserod was used for a “nonlife-threatening condition”, risk of serious
cardiovascular events was felt to be disproportionate to any potential benefit.
Brandt LJ. Am J Gastroenterol 2008.
• Large matched, case control study of tegaserod-treated patients (n = 2603), matched 1:6 with untreated (n = 15,618) patients, followed for an average of 2.5 years.
• Cardiovascular event rates were low and similar in patients treated with tegaserod and matched untreated patients. – Primary composite CV endpoint, 54 (0.35%) untreated and 12 (0.46%) treated pts had an event (treated OR
= 1.27, 95% CI: 0.68-2.38, P =.46), with 7 and 0 events, respectively, occurring within 3 months. – A total of 12 (0.1%) untreated and 1 (<0.1%) treated pts were hospitalized for a myocardial infarction (MI). – 36 (0.2%) untreated and 10 (0.4%) treated pts for a cerebrovascular accident, and 1 pt in each group for
unstable angina. – A total of 6 (<0.1%) untreated and no treated pts died from cardiac causes. Event rates were comparable to
expected rates in this population of mostly premenopausal women.
• Failed to confirm a reported large event differential for tegaserod incidentally noted in earlier clinical trials database– Suggesting that the prior observation may have been due to chance.
Tegaserod for IBS with constipationEvidence against a CV risk
Anderson JL, et al. J Cardiovasc Pharmacol Ther 2009.
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IBS Pharmacotherapy“What’s old is new again?”
IBS Pharmacotherapy“What’s old is new?”
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1. Tenapanor blocks NHE3, which transports sodium in exchange for protons
2. Blocking NHE3 increases sodium outside cells/in the gut
3. Increased sodium increases water in the gut, improving stool consistency,
alleviating constipation
IBS PharmacotherapyWhat’s New: Tenapanor for IBS-C?
Data from preclinical studies have shown that tenapanor works to reduce abdominal pain caused by IBS-C through the inhibition of TRPV-1 dependent signaling.
Source: Ardelyx website (www.ardelyx.com); accessed 10/27/18
Tenapanor for IBS-C?T3MPO-2 phase 3 study
0%
10 %
20 %
30 %
40 %
50 %
60 %
Abd Pain+CSBM* CSBM Abdomi nal pain Abd Pain+CSBM CSBM Abdomi nal pain
Tenapanor Placebo
* Primary study endpointComplete spontaneous bowel movement (CSBM) endpoint: Weekly increase in ≥1 CSBM from baseline and at least 3 CSBMs/weekAbdominal pain endpoint: ≥30% decrease in abdominal pain (0-10 scale) from baselineCombined Responder endpoint (Abd pain + CSBM): Both CSBM and abdominal pain endpoints met during the same week
≥6/12 study weeks ≥9/1st 12 study weeks AND ≥3/weeks 9-12(“Durable response”)
Source: Ardelyx website (www.ardelyx.com); accessed 10/27/18
50 mg of tenapanor (n=293) or placebo (n=300) twice-daily for 26 weeks
P<0.001
P<0.001P=0.004
% R
espo
nder
P<0.001P<0.001
P=0.028
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IBS
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What are FODMAPs?
Lentils, cabbage, brussels sprouts, asparagus,
green beans, legumes
Sorbitol
Raffinose
Honey, apples, pears, peaches, mangos, fruit
juice, dried fruit
Apricots, peaches, artificial sweeteners, artificially
sweetened gums
Wheat (large amounts), rye (large amounts), onions,
leeks, zucchini
Excess Fructose
Fructans
Fermentable Oligo-, Di-, Monosaccharides And Polyols
Shepherd SJ, et al. Clin Gastroenterol Hepatol. 2008;6:765-771; Shepherd SJ, Gibson PR. J Am Diet Assoc. 2006;106:1631-1639.
FODMAP Components Effects of on H2 production (breath testing)
DRINKS (500 ml):Glucose (40g)Fructose (40g)Fructan (40g)Glucose (40g) + Fructose (40g)
Murray K, et al. Am J Gastroenterol 2014.
=50g fructose
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Effects of FODMAP Components on Small Bowel Water Content (SBWC)
Murray K, et al. Am J Gastroenterol 2014.
70
0 7 14 21
20
40
60 60
40
20
14 21
Low FODMAP diet
FODMAP Diet in IBSReduces Functional GI Symptoms
Halmos EP et al. Gastroenterology 2014.
Effects of Diet on Functional GI Symptoms
in Controlled, Crossover Study (N=30)
VA
S (
0-1
00
mm
)
Study DayStudy Day
Typical Australian dietTypical Australian diet
Low FODMAP diet
FODMAP, fermentable oligo-di-monosaccharides and polyols; VAS, visual analog scale..
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Dietary Management of IBSIs FODMAP superior to ‘usual IBS diets’?
Eswaran SL et al. Am J Gastroenterology 2016.
• Single center RCT, 92 IBS-D patients randomized to FODMAP or Modified National Institute for Health and Care Excellence (UK) for 4 weeks
Dietary Management of IBSFODMAP > mNICE for abdominal pain and bloating
○§ §
§
1
2
3
4
5
6
Ba se lin e We ek 1 We ek 2 We ek 3 We ek 4Aver
age
Dai
ly A
bdom
inal
Pai
n Sc
ores
(0
-10)
m- NI CE Low FODM A P
#§ § §
1
2
3
4
5
6
Ba se lin e We ek 1 We ek 2 We ek 3 We ek 4
Aver
age
Dai
ly A
bdom
inal
Blo
atin
g Sc
ore
(0-1
0)
m- NI CE Low FODM A P
Abdominal Pain Scores Bloating Scores
P values refer to the change WITHIN group comparing to baseline score.*P≤0.05; oP≤0.001; §P≤0.0001.
Eswaran SL et al. Am J Gastroenterol 2016.
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FODMAP vs. mNICENo difference in adequate relief of IBS symptoms
4152
0
10
20
30
40
50
60
“In the last week, have you had adequate relief of your GI symptoms?”Proportion of patients that answered “Yes” for ≥50% of weeks 3 and 4
N=45mNICE Low FODMAP
N=38
Patie
nts w
ith
Adeq
uate
Rel
ief,
%
Adequate ReliefP=0.3055
mNICE: modified National Institute for Health and Care Excellence diet (see https://www.nice.org.uk/guidance/cg61/chapter/1-Recommendations#dietary-and-lifestyle-advice). Patients instructed to eat small frequent meals, avoid food triggers and excess alcohol and caffeine. FODMAP containing foods were not excluded from the mNICE diet.
Eswaran SL et al. Am J Gastroenterology 2016.
FODMAP vs. mNICEDifferences in macronutrient consumption
Eswaran SL et al. Am J Gastroenterology 2016.
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Gluten free diet for IBS
No significant impact on symptoms
2018 ACG Monograph: “We suggest against a gluten-free diet”
(Recommendation: Weak, Quality of Evidence: Low)
Ford AC et al. Am J Gastroenterol 2018.
Composition and Distribution of Gut Microbiota1
ÈBifidobacteria
ÈLactobacilli
ÈAnaerobes
ÇEnterobacteria
ÇAerobes
SHOULD WE USE PROBIOTICS?
Microbiome Shifts in IBS2*
*Determined by culture. Other microbiome shifts demonstrated by microarray, qPCR (quantitative polymerase chain reaction, DGGE (denaturing gradient gel electrophoresis, and FISH (fluorescence in situ hybridization). MMC, migrating motor complex.
Adapted from Simren M, et al. Gut. 2013;62:159-176; 2. Mayer EA, et al. Gastroenterology. 2014;146:1500-1512.
Gut microbiota are altered in IBS
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Probiotics for IBSBest evidence with combination and Bifidobacterium preparations
• 53 RCTs involving 5455 IBS patients
• Overall, superior to placebo (RR of IBS not improving = 0.81, 95% CI 0.74-0.88), NNT=7
• Improvement in global IBS symptoms, abdominal pain, bloating, and flatulence
• Insufficient and conflicting data prevent making recommendations about any individual species, preparation, or strain.1
• Multiple microbiologic studies demonstrate that probiotics do not contain viable bacterial species as listed on the label.2-5
• ACG Monograph: Recommendation: weak, Quality of Evidence: very low
1. Ford AC et al. Am J Gastroenterol 2018. 2. 2. Sanders ME, Levy DD. Ann NY AcadSci. 2011 3. Yeung PS et al. J Dairy Sci. 2002. 4. Temmerman R et al. Int J Food Microbiol. 2003. 5. Drisko J et al. Dig Dis Sci. 2005
Prebiotics for IBSAs effective as low FODMAP(with continued benefit)
LFD = low FODMAP dietHuaman et al. Gastroenterol 2018.
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-22.6 -19.2-25.4
-42.4-34.1
-48.1
0
20
40
60
80
100
Abdo minal Painor Discomfor t
Abdo minalBloating orDistension
Pain atEvacuation
Sym
ptom
red
uctio
n, %
AEs, adverse events; RCT, randomized controlled trial; TISS, Total IBS Symptom Score
Triple-Coated Peppermint Oil for IBSEffective for overall symptom improvement
Placebo TID (n=37)
Peppermint oil 180 mg TID (n=35)
**
*
Symptom Reduction at Day 29• RCT of triple-coated peppermint oil
microspheres in IBS-M or IBS-D (N=72)Ø Randomized to peppermint oil†
180 mg TID or placebo for 4 weeks
Ø Primary analysis based on TISS
• Peppermint oil improved TISS (P<0.02) and frequency and intensity of individual IBS symptoms over 4 weeks
• Most frequent AE with peppermint oil and placebo was dyspepsia/heartburn (2.9% vs 0%)
• Results may not extrapolate to other peppermint/menthol preparations
• NNT of 4
* p<0.05
Cash BD et al. Dig Dis Sci. 2016;61:560-571.
STW 5 for IBSImprovement in global symptoms and abdominal pain
N=208 IBS subjects, randomized to STW 5 (n=52, proprietary commercially available 9 plant extract), STW 5-II (experimental plant extract), bitter candytuft extract, or placebo
Madisch A et al. Aliment Pharmacol Ther 2004.
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Fiber Supplements for IBSSoluble fiber (psyllium)>insoluble (bran)
• 15 RCTs involving 946 IBS patients
• Significant effect of fiber vs. placebo– RR of IBS not improving =0.87, 95% CI 0.80-0.94)
– Bran had NO significant effect (RR=0.90, 95% CI 0.79-1.03)
• May ferment, exacerbate pain and gas-bloat symptoms
– Ispaghula effective in treating IBS (RR=0.83, 95% CI 0.73-0.94)
• Low cost, lack of side effects make soluble fiber a reasonable therapy– Improved stool viscosity, frequency in IBS-C
• ACG Monograph: Recommendation: strong, Quality of evidence: moderate
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Sleep and Hyperalgesia
“Good sleep”: ≥8 hoursBad sleep: <3 hours
1. Hiestand D et al. Chest 2006. 2. Chiu Y et al. Pain 2005. 3. Hakki Onen S et al. J Sleep Res 2001. 4. Schey R et al. Gastroenterol 2007. 5. Finan PH et al. J Pain 2013.
• Sleep deprivation (<7 hours night) is common, may affect up to 70% of adults1
• Subjects with self-reported disturbances in sleep have lower pain thresholds2
• Decreased tolerance thresholds to mechanical and thermal pain during sleep deprivation using a pressure dolorimeter and a thermode3
• Increased acid sensitivity in both healthy individuals and GERD patients with “bad sleep”4
• May relate to dysregulation of mu-opioid receptor responses to endogenous opioidergic system5
Disturbed Sleep and IBSA potential target for intervention?
Sleep duration (mins)
Longer undisturbed sleep episode
Mean sleep episode duration
Waking episodes during sleep
• IBS subjects (n=24) and healthy controls (n=26) monitored for 1 week with sleep actigraphy and daily symptom journals
• Poor sleep (waking episodes) predictive of worse GI symptoms in IBS only
• Sleep disturbances not related to GI symptoms
• Recommend focus on: sleep hygiene, caffeine/EtOH avoidance, no late meals, sunlight during day, melatonin
Patel A et al. Aliment Pharmacol Ther 2016.
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• Exercise protective against GI symptoms1 and improves colon transit2 in healthy volunteers
• IBS subjects (N=75) randomized to supervised physical activity or to maintain their lifestyle for 12 weeks2
• Increased physical activity improved IBS-SSS scores (P=0.003)
• Proportion of patients with worsened IBS symptoms was significantly higher in control group than in physical activity group
• Long term follow-up study (n=39, median 5 years): continued increased activity, symptom improvement3 1.
2. Johannesson E et al. Am J Gastroenterol. 20113. Johanesson E et al. World J Gastroenterol 2015.
IBS
Seve
rity
Sco
re
500
400
300
200
100
0
Control group Physical activity group
P = 0.001
Start 12 Weeks
Exercise for IBSImproved symptom severity with a durable effect
Yoga for IBS PatientsGood for the body (and the bowel!)
• 6 RCTs, n=273 IBS patients– In meta-analysis, beneficial effect of a yogic
intervention over conventional IBS treatment in IBS
– Significantly decreased bowel symptoms, IBS severity, and anxiety.
• Improvements in quality of life, global improvement, and physical functioning
• Yoga comparably effective as low FODMAP diet
Schumann D et al. Clin Gastroenterol Hepatol 2016.Schumann D et al. Aliment Pharmacol Ther 2017.
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Lackner J et al. Gastroenterol 2018.
Cognitive Behavioral Therapy (CBT) for IBSMinimal contact (and standard) CBT improves refractory IBS symptoms
IBS Management: Small Steps to Big ImprovementsA golf analogy
“Drive for show, putt for dough.” --Arthur D'Arcy "Bobby" Locke (1917 –1987)
Pharmacotherapy DietExercise/yoga
SleepPsychologicalSupplements
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