No ‘one right answer’ among pharmacologic, non-pharmacologic IBS therapies
PHILADELPHIA – Given the vast number and varying kinds of therapies currently available for the treatment of irritable bowel syndrome, choosing the right one comes down to many different factors.
In their presentations given at the American College of Gastroenterology Annual Scientific Meeting, Lin Chang, MD, FACG, of the David Geffen School of Medicine at UCLA and William Chey, MD, FACG, of the division of gastroenterology at the University of Michigan Health System, offered insights into both pharmacologic and non-pharmacologic therapies for IBS.
Chang said that when she is determining the best medical therapy for her patients with IBS, she first evaluates their symptoms to find the right target.
“When I think about IBS, I think about what mechanism I’m trying to target and what treatment would be helpful for that particular mechanism,” she said during her presentation in the Functional Disorders postgraduate course.
In patients with constipation-predominant IBS with gastrointestinal motility or transit problems, that could mean recommending fiber supplements or laxatives. If patients with IBS-C are experiencing visceral hypersensitivity or abdominal pain, they might see a benefit from antispasmodics or low-doses of antidepressant medicines.
“Say a patient’s constipation is getting better, but they still have pain that’s not linked to bowel habits,” Chang said. “That’s when you want to think about using a neuromodulator, a tricyclic agent or [Serotonin and norepinephrine reuptake inhibitor].”
One agent that Chang said could be used in either subset of patients was Trulance (plecanatide, Synergy). Trulance, a guanylate cyclase-C agonist, was recently tested in three randomized controlled trials that found it offered patients significant improvements to both abdominal pain and complete spontaneous bowel movements compared with placebo.
Chang said that if patients with diarrhea-predominant IBS don’t respond to dietary intervention it is important to consider their predominant symptoms before choosing a therapy.
“If it’s diarrhea and not pain, you can think about luminal antibiotics, bile acid binders, and then we have the opioid agonist and antagonists,” she said. “If the patient has some good control on their diarrhea but is still experiencing some pain, that’s when we want to think about what we thought about with IBS-C. Low dose TCAs, pure SNRI, and behavioral therapy. You can use combinations of these treatments. I find that works best for IBS, especially for moderate-to-severe. You want to have a multidisciplinary approach.”
“It’s an exciting time in IBS,” Chey said during his presentation. “I’m growing increasingly excited and optimistic about the future and about what’s going to happen with IBS.”
Optimistic, he said, because people are paying more attention to non-pharmacologic therapies for patients with IBS. He broke those therapies down into three categories:
- Behavioral therapies
- Complementary alternative medical therapies
There are several popular diets, including the ketogenic diet and paleo diets, that patients have started to turn to in search of relief. However, Chey said he has not found any evidence to support their use in IBS, but thought they were at least worth looking into.
“These diets are very popular, and people are trying them,” he said. “It would be interesting to evaluate these diets in clinical trials of patients with IBS.”
However, researchers have looked extensively into the low-FODMAP diet. Chey highlighted several trials that explored the benefit of a low-FODMAP diet for IBS, including a meta-analysis that found it was associated with reduced overall symptoms compared with a control diet. Additional studies found that it improved weekly abdominal pain and bloating scores, as well as patient quality of life scores.
Although current AGA guidelines recommend using psychological treatments for patients with moderate-to-severe IBS who have failed to respond to medical treatments, Chey said he tended to disagree based on the number of patients he’s seen improve in University of Michigan Health System clinics alone.
“I don’t think it’s for only these patients,” he said. “Hopefully this statement will be updated as the literature evolves.”
Evidence has shown that cognitive behavioral therapy helped patients improve IBS symptoms and has even shown to be at least as effective as medical therapies, Chey said.
“There’s no doubt that behavioral therapy is an effective tool for a subset of individuals with IBS,” he said. “When you look at the number needed to treat based on the trials that have been evaluated, for CBT and gut-directed hypnosis, the number needed to treat is in the 2-3 range. You can’t really reliably compare NNTs across trials, but that’s at least as good as the medical therapies that we currently have available to us. “
As for complementary alternative medical therapies, Chey said there is compelling evidence that shows the benefit of acupuncture and yoga for patients with IBS.
“Perhaps we should be looking at acupuncture as an evidence-based treatment for our patients with constipation,” he said. “We clearly need more literature on this particular topic, but I think there’s some very interesting fodder out there that should make a stink. Especially given that yoga is a very low risk intervention in patients with IBS.”
When treating patients with IBS, there might not be one right answer. Chey said more than one therapy is often required.
“Integrative, multi-disciplinary care is increasingly the rules rather than the exception,” he said. “Especially for moderate-to-severely affected patients with IBS.” – by Alex Young
Reference : Chang, L. “Pharmacologic Treatment of IBS.” Presented at: American College of Gastroenterology Annual Scientific Meeting; Oct. 5-10, 2018; Philadelphia.
Chey, W. “Non-Pharmacologic Treatment of IBS.” Presented at: American College of Gastroenterology Annual Scientific Meeting; Oct. 5-10, 2018; Philadelphia.
Disclosures: Chang reports financial ties to Allergan, Ardelyx, Biomerica, Cairn Diagnostics, IM HealthScience, Syngery, and Takeda. Chey reports financial ties to MyGiHealth, Nestle and True Self Foods.