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ACG updates recommendations for management of IBS, chronic idiopathic constipation
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The American College of Gastroenterology has published an updated systematic review of data for the management of irritable bowel syndrome and chronic idiopathic constipation.
Updating data last compiled in 2009, the review was designed to provide physicians with the most current evidence on best care practices for patients with irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC; or functional constipation).
“In order to evaluate the rapidly expanding research about IBS and CIC and to assess the evidence of efficacy of new IBS and constipation drugs, ACG sponsored an independent, systematic review, and all available studies were reviewed by the ACG Functional Bowel Disorders Task Force … in order to update the recommendations,” Eamonn M.M. Quigley, MD, FACG, and chairman of the task force, said in an ACG press release. “Studies meeting pre-specified criteria that were selected to minimize bias were examined in detail and summarized. When possible, results were combined by a formal meta-analysis to improve the reliability of conclusions.”
Eamonn M.M. Quigley
Highlights of recommendations for IBS therapies:
- Elimination diets (more evidence needed)
- Fiber (stronger evidence for psyllium compared with bran)
- Probiotics improve global symptoms, bloating and flatulence
- Rifaxamin (moderate evidence for treating IBS with diarrhea)
- Linaclotide and lubiprostone (strongly recommended for IBS with constipation)
- Antidepressants and psychological therapies (improved evidence since previous recommendations)
- Prebiotics and synbiotics (insufficient evidence of effect)
Highlights of recommendations for CIC:
- Fiber supplements (strongly recommended)
- Laxatives (strongly recommended)
- Prucalopride, lubiprostone and linaclotide (strongly recommended)
“Low FODMAP diet is a promising therapeutic strategy, but more larger trials are needed,” Alexander C. Ford, MBChB, MD, FRCP, associate professor, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, and participating researcher, told Healio.com/Gastroenterology. “There is no evidence for exclusion diets, and evidence for prebiotics or synbiotics is limited. Taking the data as a whole, probiotics appear to be effective, but trying to tease out which individual strain or species is effective is difficult.
Alexander C. Ford
“Soluble fiber (ispaghula aka psyllium aka metamucil) is of benefit, and this has been confirmed again recently in a large primary care-based trial from Holland. There is no evidence of any benefit of insoluble fiber (eg, bran).”
Commenting on a related study, Ford said previously, “Tricyclic antidepressants probably work in IBS, but more studies that are rigorously designed are required. Psychological therapies may also work, particularly hypnotherapy, but access to these is limited.”– by Adam Leitenberger
Disclosure: See the study for a full list of relevant financial disclosures.
Perspective
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Braden Kuo, MD
Irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC) are extremely common issues for gastroenterologists and clinicians face an overwhelming myriad of possible treatment choices. The enormous number of therapies available usually suggests that each individual treatment is not decisively effective for all patients with these disorders. But how is a clinician able to synthesize the burgeoning literature possible options?
The ACG updates on recommendations for management for IBS and CIC can help with a review of the literature and a grading of the strength of the evidence. As a result, elimination diets and the impacts of fiber are acknowledged for IBS and serotonergic and chloride channel modulators for CIC are recognized.
But just because there is not sufficiently strong evidence, does not mean that a specific therapy is not entirely ineffective. More research in these areas may be needed to provide support while managing issues such as correctly defined patient populations, placebo effects and other issues with trial design that can affect results.
Clinical trial endpoints for IBS trials continue to evolve for IBS although constipation trials endpoints seem stable. But interestingly, there are still a number of patients who still do not respond to even the new medical options, particularly severe CIC.
As our understanding of IBS and CIC evolves and more treatments are developed, periodic reviews with guidelines are extremely helpful for the busy GI clinician.
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