Healio Hot Topic

Working With Patients to Pick the Right Alternative IBS Treatment

Over the past few years, more and more options have become available to treat irritable bowel syndrome.

However, there is no great algorithm that tells us, “if a patient has IBS, this is the first drug to use and this is how you ramp up.” It comes down to what therapy will best treat the predominant symptoms and addressing those that affect their quality of life the most.

Linda Nguyen, MD
Linda Nguyen

It is important that we take patient preference into account. For example, in constipation-predominant IBS, some patients do not like the idea of taking a drug every day because they worry that they will become dependent on that medication. As clinicians, we need to listen to these wishes and partner with our patients to provide them with meaningful tools to help them manage and control their disease rather than be at the mercy of their gut. We have prescription medications approved for IBS constipation and IBD diarrhea that are very effective for some patients, but ineffective in the majority in clinical trials. These studies and real world patient experiences finds that when patients discontinue any of these therapies, their symptoms return. Given the chronic nature of IBS and concerns over taking lifelong medications, patients often seek alternative therapies for IBS.

Alternative Treatments

IBS is a very common disease that impacts millions of lives. Despite the increasing numbers of commercially available prescriptions for IBS, many patients are still left dissatisfied by these medications. That leads a lot of those individuals to take the management of their disease into their own hands.

Studies have shown that more than half of patients with IBS use complementary or alternative therapies. Further, most of these patients will not tell their physicians about it because they think it is not necessary or not relevant. They might be worried that their doctors will dismiss them or frown upon what they are doing. We know many of our patients are already implementing these therapies; yet, we have been slow to adopt these therapies into our practices. We need to be open to alternative therapies and encourage our patients to share what they are doing with us. We need to know what is being done, so we can guide patients in a way that allows them to choose complementary therapies that are effective and safe.

One of the most common alternative therapies is probiotics. There is an explosion of interest in the microbiome in health and disease. Naturally, people turn to probiotics in hopes that taking them will lead to greater health. Unfortunately, there are insufficient data to support the use of probiotics in IBS. Studies have been heterogeneous with use of single and combination strains. Despite the lack of evidence, in 2012, it was estimated that more than $30 billion was spent on probiotics. Although this was an overall estimate and not just for IBS, it helps to illustrate the financial burden of IBS on patients.

Dietary intervention is common among patients with IBS. Most common dietary changes attempted by patients are elimination diets on a trial and error basis. The low FODMAP diet, which has been studied the most carefully, can be quite beneficial for patients with IBS. However, patients are often left to their own devices to implement the diet with either a simple handout or internet searches. The low FODMAP diet is a complex diet that is highly restrictive and not meant to be a “forever” NO FODMAP diet. Used correctly (ideally with the aid of a registered dietitian) the diet has three phases: restriction, reintroduction and maintenance. The “restriction” phase should be no more than 2 to 4 weeks. Being ultra-restrictive may help improve symptoms; however, it may negatively impact their quality of life and socialization. People often find joy in eating; thus, a restrictive diet can feel overwhelming. The low FODMAP diet is not for everyone. Approximately 40% of patients do not respond to a low FODMAP diet despite strict implementation. Without blaming the individual, the diet must be discontinued and move on to other therapies. Before recommending dietary interventions, we must be aware of potential eating disorders, specifically avoidant restrictive feeding disorder (ARFID), which develops as a response to eating causing pain.

As physicians, we can work with patients to discuss the pros and cons of these and other alternative therapies, including herbs and supplements, which are poorly regulated. Herbal blends, supplements and medical foods, such as STW-5, glutamine and peppermint oil have been shown in small trials to be beneficial for IBS. Magnesium, prunes and kiwis can help with constipation. It is important that we are able to have a discussion without patients about the pros, cons and limitations of each of these alternative therapies.

Brain-directed therapies such as gut-directed hypnosis, cognitive behavioral therapy, and mindfulness meditation are also beneficial to patients. The challenge in implementing these therapies are the stigma that still exits with psychological therapies, cost and lack of access due to limited skilled therapists.

The role of mind-body therapy and complementary or alternative therapies has become “mainstream” among patients with IBS. Physicians need to work from the understanding that our patients are literally hungry for non-prescription therapies. We must include these options in our armamentarium to discuss with our patients so we can guide and coach them through the process of taking back control of their digestive health and symptoms.

Disclosure: Nguyen reports serving as a consultant for Ironwood and Salix. Nguyen also reports receiving research funding from Allergan.

Over the past few years, more and more options have become available to treat irritable bowel syndrome.

However, there is no great algorithm that tells us, “if a patient has IBS, this is the first drug to use and this is how you ramp up.” It comes down to what therapy will best treat the predominant symptoms and addressing those that affect their quality of life the most.

Linda Nguyen, MD
Linda Nguyen

It is important that we take patient preference into account. For example, in constipation-predominant IBS, some patients do not like the idea of taking a drug every day because they worry that they will become dependent on that medication. As clinicians, we need to listen to these wishes and partner with our patients to provide them with meaningful tools to help them manage and control their disease rather than be at the mercy of their gut. We have prescription medications approved for IBS constipation and IBD diarrhea that are very effective for some patients, but ineffective in the majority in clinical trials. These studies and real world patient experiences finds that when patients discontinue any of these therapies, their symptoms return. Given the chronic nature of IBS and concerns over taking lifelong medications, patients often seek alternative therapies for IBS.

Alternative Treatments

IBS is a very common disease that impacts millions of lives. Despite the increasing numbers of commercially available prescriptions for IBS, many patients are still left dissatisfied by these medications. That leads a lot of those individuals to take the management of their disease into their own hands.

Studies have shown that more than half of patients with IBS use complementary or alternative therapies. Further, most of these patients will not tell their physicians about it because they think it is not necessary or not relevant. They might be worried that their doctors will dismiss them or frown upon what they are doing. We know many of our patients are already implementing these therapies; yet, we have been slow to adopt these therapies into our practices. We need to be open to alternative therapies and encourage our patients to share what they are doing with us. We need to know what is being done, so we can guide patients in a way that allows them to choose complementary therapies that are effective and safe.

One of the most common alternative therapies is probiotics. There is an explosion of interest in the microbiome in health and disease. Naturally, people turn to probiotics in hopes that taking them will lead to greater health. Unfortunately, there are insufficient data to support the use of probiotics in IBS. Studies have been heterogeneous with use of single and combination strains. Despite the lack of evidence, in 2012, it was estimated that more than $30 billion was spent on probiotics. Although this was an overall estimate and not just for IBS, it helps to illustrate the financial burden of IBS on patients.

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Dietary intervention is common among patients with IBS. Most common dietary changes attempted by patients are elimination diets on a trial and error basis. The low FODMAP diet, which has been studied the most carefully, can be quite beneficial for patients with IBS. However, patients are often left to their own devices to implement the diet with either a simple handout or internet searches. The low FODMAP diet is a complex diet that is highly restrictive and not meant to be a “forever” NO FODMAP diet. Used correctly (ideally with the aid of a registered dietitian) the diet has three phases: restriction, reintroduction and maintenance. The “restriction” phase should be no more than 2 to 4 weeks. Being ultra-restrictive may help improve symptoms; however, it may negatively impact their quality of life and socialization. People often find joy in eating; thus, a restrictive diet can feel overwhelming. The low FODMAP diet is not for everyone. Approximately 40% of patients do not respond to a low FODMAP diet despite strict implementation. Without blaming the individual, the diet must be discontinued and move on to other therapies. Before recommending dietary interventions, we must be aware of potential eating disorders, specifically avoidant restrictive feeding disorder (ARFID), which develops as a response to eating causing pain.

As physicians, we can work with patients to discuss the pros and cons of these and other alternative therapies, including herbs and supplements, which are poorly regulated. Herbal blends, supplements and medical foods, such as STW-5, glutamine and peppermint oil have been shown in small trials to be beneficial for IBS. Magnesium, prunes and kiwis can help with constipation. It is important that we are able to have a discussion without patients about the pros, cons and limitations of each of these alternative therapies.

Brain-directed therapies such as gut-directed hypnosis, cognitive behavioral therapy, and mindfulness meditation are also beneficial to patients. The challenge in implementing these therapies are the stigma that still exits with psychological therapies, cost and lack of access due to limited skilled therapists.

The role of mind-body therapy and complementary or alternative therapies has become “mainstream” among patients with IBS. Physicians need to work from the understanding that our patients are literally hungry for non-prescription therapies. We must include these options in our armamentarium to discuss with our patients so we can guide and coach them through the process of taking back control of their digestive health and symptoms.

Disclosure: Nguyen reports serving as a consultant for Ironwood and Salix. Nguyen also reports receiving research funding from Allergan.