How to meet the challenges of managing patients with IBS

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doi:doi: 10.12788/jfp.0299

Applied Evidence

How to meet the challenges of managing patients with IBS

J Fam Pract. 2021 November;70(9):431-441 | doi: 10.12788/jfp.0299

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References

1. Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150:1393-1407.e5. doi:10.1053/j.gastro.2016.02.031

2. What kind of poop do I have? WebMD. January 16, 2020. Accessed September 20, 2021. www.webmd.com/digestive-disorders/poop-chart-bristol-stool-scale

3. Ford AC, Moayyedi P, Chey WD, et al; ACG Task Force on Management of Irritable Bowel Syndrome. American College of Gastroenterology monograph on management of irritable bowel syndrome. Am J Gastroenterol. 2018;113(suppl 2):1-18. doi:10.1038/s41395-018-0084-x

4. Ferreira AI, Garrido M, Castro-Poças F. Irritable bowel syndrome: news from an old disorder. GE Port J Gastroenterol. 2020;27:255-268. doi:10.1159/000503757

5. Black CJ, Ford AC. Global burden of irritable bowel syndrome: trends, predictions and risk factors. Nat Rev Gastroenterol Hepatol. 2020;17:473-486. doi: 10.1038/s41575-020-0286-8

6. Frändemark Å, Törnblom H, Jakobsson S, et al. Work productivity and activity impairment in irritable bowel syndrome (IBS): a multifaceted problem: Am J Gastroenterol. 2018;113:1540-1549. doi:10.1038/s41395-018-0262-x

7. Poulsen CH, Eplov LF, Hjorthøj C, et al. Irritable bowel symptoms, use of healthcare, costs, sickness and disability pension benefits: a long-term population-based study. Scand J Public Health. 2019;47:867-875. doi:10.1177/1403494818776168

8. Hausteiner-Wiehle C, Henningsen P. Irritable bowel syndrome: relations with functional, mental, and somatoform disorders. World J Gastroenterol. 2014;20:6024-6030. doi:10.3748/wjg.v20.i20.6024

9. Moayyedi P, Mearin F, Azpiroz F, et al. Irritable bowel syndrome diagnosis and management: a simplified algorithm for clinical practice. United European Gastroenterol J. 2017;5:773-788. doi:10.1177/2050640617731968

10. Zhu S, Wang B, Jia Q, et al. Candidate single nucleotide polymorphisms of irritable bowel syndrome: a [systematic] review and meta-analysis. BMC Gastroenterology. 2019;19:165. doi:10.1186/s12876-019-1084-z

11. Simrén M, Törnblom H, Palsson OS, et al. Visceral hypersensitivity is associated with GI symptom severity in functional GI disorders: consistent findings from five different patient cohorts. Gut. 2018;67:255-262. doi:10.1136/gutjnl-2016-312361

12. Bashashati M, Moossavi S, Cremon C, et al. Colonic immune cells in irritable bowel syndrome: a systematic review and meta-analysis. Neurogastroenterol Motil. 2018;30:e13192. doi:10.1111/nmo.13192

13. Robles A, Ingles DP, Myneedu K, et al. Mast cells are increased in the small intestinal mucosa of patients with irritable bowel syndrome: a systematic review and meta-analysis. Neurogastroenterol Motil. 2019;31:e13718. doi:10.1111/nmo.13718

14. Bashashati M, Moradi M, Sarosiek I. Interleukin-6 in irritable bowel syndrome: A systematic review and meta-analysis of IL-6 (-G174C) and circulating IL-6 levels. Cytokine. 2017;99:132-138. doi:10.1016/j.cyto.2017.08.017

15. Bashashati M, Rezaei N, Shafieyoun A, et al. Cytokine imbalance in irritable bowel syndrome: a systematic review and meta-analysis. Neurogastroenterol Motil. 2014;26:1036-1048. doi:10.1111/nmo.12358

16. Sibelli A, Chalder T, Everitt H, et al. A systematic review with meta-analysis of the role of anxiety and depression in irritable bowel syndrome onset. Psychol Med. 2016;46:3065-3080. doi:10.1017/S0033291716001987

17. Yeh H-W, Chien W-C, Chung C-H, et al. Risk of psychiatric disorders in irritable bowel syndrome—a nationwide, population-based, cohort study. Int J Clin Pract. 2018;72:e13212. doi:10.1111/ijcp.13212

18. Duan R, Zhu S, Wang B, et al. Alterations of gut microbiota in patients with irritable bowel syndrome based on 16S rRNA-targeted sequencing: a systematic review. Clin Transl Gastroenterol. 2019;10:e00012. doi:10.14309/ctg.0000000000000012

19. Wang L, Alammar N, Singh R, et al. Gut microbial dysbiosis in the irritable bowel syndrome: a systematic review and meta-analysis of case-controlled studies. J Acad Nutr Diet. 2020;120:565-586. doi:10.1016/j.jand.2019.05.015

20. Barbara G, Grover M, Bercik P, et al. Rome Foundation working team report on post-infection irritable bowel syndrome. Gastroenterology. 2019;156:46-58.e7. doi:10.1053/j.gastro.2018.07.011

21. Klem F, Wadhwa A, Prokop LJ, et al. Prevalence, risk factors, and outcomes of irritable bowel syndrome after infectious enteritis: a systematic review and meta-analysis. Gastroenterology. 2017;152:1042-1054.e1. doi:10.1053/j.gastro.2016.12.039

22. Heidelbaugh JJ. These 3 tools can help you streamline management of IBS. J Fam Pract. 2017;66:346-353.

23. American College of Gastroenterology Task Force on Irritable Bowel Syndrome; Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009;104(suppl 1):S1-S35. doi:10.1038/ajg.2008.122

24. Menees SB, Powell C, Kurlander J, et al. A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS. Am J Gastroenterol. 2015;110:444-454. doi:10.1038/ajg.2015.6

25. Smalley W, Falck-Ytter C, Carrasco-Labra A, et al. AGA clinical practice guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). Gastroenterology. 2019;157:851-854. doi:10.1053/j.gastro.2019.07.004

26. Markham A. Tenapanor: first approval. Drugs. 2019;79:1897-1903. doi:10.1007/s40265-019-01215-9

27. Chey WD, Paré P, Viegas A, et al. Tegaserod for female patients suffering from IBS with mixed bowel habits or constipation: a randomized controlled trial. Am J Gastroenterol. 2008;103:1217-1225. doi:10.1111/j.1572-0241.2008.01808.x

28. Zhou C, Zhao E, Li Y, et al. Exercise therapy of patients with irritable bowel syndrome: a systematic review of randomized controlled trials. Neurogastroenterol Motil. 2019;31:e13461. doi:10.1111/nmo.13461

29. Hustoft TN, Hausken T, Ystad SO, et al. Effects of varying dietary content of fermentable short-chain carbohydrates on symptoms, fecal microenvironment, and cytokine profiles in patients with irritable bowel syndrome. Neurogastroenterol Motil. 2017;29:e12969. doi:10.1111/nmo.12969

30. Zegarac JP. The low-FODMAP diet for IBS: what you need to know. Medscape. August 13, 2019. Accessed September 20, 2021. www.medscape.com/viewarticle/917069

31. Dionne J, Ford AC, Yuan Y, et al. A systematic review and meta-analysis evaluating the efficacy of a gluten-free diet and a low fodmaps diet in treating symptoms of irritable bowel syndrome: Am J Gastroenterol. 2018;113:1290-1300. doi:10.1038/s41395-018-0195-4

32. Su H, Li Y-T, Heitkemper MM, et al. Effects of low-FODMAPS diet on irritable bowel syndrome symptoms and gut microbiome: Gastroenterol Nurs. 2019;42:150-158. doi:10.1097/SGA.0000000000000428

33. Nawawi KNM, Belov M, Goulding C. Low FODMAP diet significantly improves IBS symptoms: an Irish retrospective cohort study. Eur J Nutr. 2020;59:2237-2248. doi: 10.1007/s00394-019-02074-6

34. Altobelli E, Del Negro V, Angeletti PM, et al. Low-FODMAP diet improves irritable bowel syndrome symptoms: a meta-analysis. Nutrients. 2017;9:940. doi:10.3390/nu9090940

35. Nagarajan N, Morden A, Bischof D, et al. The role of fiber supplementation in the treatment of irritable bowel syndrome: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2015;27:1002-1010. doi:10.1097/MEG.0000000000000425

36. Wilson B, Rossi M, Dimidi E, et al. Prebiotics in irritable bowel syndrome and other functional bowel disorders in adults: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr. 2019;109:1098-1111. doi:10.1093/ajcn/nqy376

37. Yuan F, Ni H, Asche CV, et al. Efficacy of Bifidobacterium infantis 35624 in patients with irritable bowel syndrome: a meta-analysis. Curr Med Res Opin. 2017;33:1191-1197. doi:10.1080/03007995.2017.1292230

38. Liang D, Longgui N, Guoqiang X. Efficacy of different probiotic protocols in irritable bowel syndrome: a network meta-analysis. Medicine (Baltimore). 2019;98:16068. doi:10.1097/MD.0000000000016068

39. Dale HF, Rasmussen SH, Asiller ÖÖ, et al. Probiotics in irritable bowel syndrome: an up-to-date systematic review. Nutrients. 2019;11:2048. doi:10.3390/nu11092048

40. Pratt C, Campbell MD. The effect of Bifidobacterium on reducing symptomatic abdominal pain in patients with irritable bowel syndrome: a systematic review. Probiotics Antimicrob Proteins. 2020;12:834-839. doi:10.1007/s12602-019-09609-7

41. Ianiro G, Eusebi LH, Black CJ, et al. Systematic review with meta-analysis: efficacy of faecal microbiota transplantation for the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2019;50:240-248. doi:10.1111/apt.15330

42. Myneedu K, Deoker A, Schmulson MJ, et al. Fecal microbiota transplantation in irritable bowel syndrome: a systematic review and meta-analysis. United European Gastroenterol J. 2019;7:1033-1041. doi:10.1177/2050640619866990

43. Xu D, Chen VL, Steiner CA, et al. Efficacy of fecal microbiota transplantation in irritable bowel syndrome: a systematic review and meta-analysis. Am J Gastroenterol. 2019;114:1043-1050. doi:10.14309/ajg.0000000000000198

44. Black CJ, Yuan Y, Selinger CP, et al. Efficacy of soluble fibre, antispasmodic drugs, and gut–brain neuromodulators in irritable bowel syndrome: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol. 2020;5:117-131. doi:10.1016/S2468-1253(19)30324-3

45. Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014;48:505-512. doi:10.1097/MCG.0b013e3182a88357

46. Alammar N, Wang L, Saberi B, et al. The impact of peppermint oil on the irritable bowel syndrome: a meta-analysis of the pooled clinical data. BMC Complement Altern Med. 2019;19:21. doi:10.1186/s12906-018-2409-0

47. Ford AC, Lacy BE, Harris LA, et al. Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol. 2019;114:21-39. doi: 10.1038/s41395-018-0222-5

48. Shah ED, Kim HM, Schoenfeld P. Efficacy and tolerability of guanylate cyclase-c agonists for irritable bowel syndrome with constipation and chronic idiopathic constipation: a systematic review and meta-analysis. Am J Gastroenterol. 2018;113:329-338. doi:10.1038/ajg.2017.495

49. Black CJ, Burr NE, Quigley EMM, et al. Efficacy of secretagogues in patients with irritable bowel syndrome with constipation: systematic review and network meta-analysis. Gastroenterology. 2018;155:1753-1763. doi:10.1053/j.gastro.2018.08.021

50. Li F, Fu T, Tong W-D, et al. Lubiprostone is effective in the treatment of chronic idiopathic constipation and irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2016;91:456-468. doi:10.1016/j.mayocp.2016.01.015

51. Ford AC, Harris LA, Lacy BE, et al. Systematic review with meta-analysis: the efficacy of prebiotics, probiotics, synbiotics and antibiotics in irritable bowel syndrome. Aliment Pharmacol Ther. 2018;48:1044-1060. doi:10.1111/apt.15001

52. Yoon K, Kim N, Lee JY, et al. Clinical response of rifaximin treatment in patients with abdominal bloating. Korean J Gastroenterol. 2018;72:121-127. doi:10.4166/kjg.2018.72.3.121

53. Black CJ, Burr NE, Camilleri M, et al. Efficacy of pharmacological therapies in patients with IBS with diarrhoea or mixed stool pattern: systematic review and network meta-analysis. Gut. 2020;69:74-82. doi:10.1136/gutjnl-2018-318160

54. Lacy BE. Review article: an analysis of safety profiles of treatments for diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2018;48:817-830. doi:10.1111/apt.14948

55. Zheng Y, Yu T, Tang Y, et al. Efficacy and safety of 5-hydroxytryptamine 3 receptor antagonists in irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials. PLOS ONE. 2017;12:e0172846. doi:10.1371/journal.pone.0172846

56. Zheng H, Chen R, Zhao X, et al. Comparison between the effects of acupuncture relative to other controls on irritable bowel syndrome: a meta-analysis. Pain Research and Management. 2019;2019:1-13. doi:https://doi.org/10.1155/2019/2871505

57. Yan J, Miao Z-W, Lu J, et al. Acupuncture plus Chinese herbal medicine for irritable bowel syndrome with diarrhea: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2019;2019:1-16. https://doi.org/10.1155/2019/7680963

Treatment of IBS-C

Prosecretory agents. Linaclotide and plecanatide are amino-acid peptides that act as a guanylate cyclase C agonist. Both increase gastrointestinal transit rate by increasing electrolyte and fluid transport into the intestinal lumen. They also decrease the activity of pain-sensing nerves by increasing extracellular cyclic guanosine-3'5'-monophosphate levels.^3,48 In a recent meta-analysis, both treatments produced improvement in global symptoms. However, linaclotide showed superior improvement in abdominal pain and global symptoms compared to other secretory agents.^48,49 Diarrhea was the most common adverse effect of linaclotide and plecanatide, although less so with plecanatide.⁴⁹

Lubiprostone activates the intestinal chloride channel type 2 on the small intestine, leading to an increase in chloride and water efflux into the intestinal lumen, in turn accelerating gastrointestinal transit.³ A meta-analysis with 1468 IBS patients found that lubiprostone improved constipation, stool consistency, abdominal pain, degree of straining, and abdominal bloating.⁵⁰ Diarrhea and nausea are commonly reported adverse effects of lubiprostone.^49,50

Linaclotide, plecanatide, and lubiprostone should be considered first-line therapies for patients with IBS-C. High cost is still a roadblock to the use of these agents.

Use antispasmodic medications as first-line treatment for mild IBS symptoms.

The US Food and Drug Administration (FDA) approved tenapanor in September 2019; however, the drug is not commercially available in the United States (it is available in Canada). Tenapanor is a sodium–hydrogen exchanger 3 inhibitor that reduces sodium absorption from the intestine and colon. The drug increases water secretion into the intestinal lumen, thus accelerating gut transit time. It also inhibits active absorption of phosphate in the intestine.

Tenapanor was approved for treating both IBS-C and hyperphosphatemia in patients with chronic kidney disease on dialysis or end-stage renal disease.²⁶ In a recent meta-analysis, the drug showed benefit in alleviating global IBS symptoms, and ranked first in reducing bloating.⁴⁹ It is too soon to know if tenapanor will perform clinically better than other prosecretory agents.

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