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Multidisciplinary care improves functional GI symptoms
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SAN DIEGO — Patients with functional gastrointestinal disorders who underwent 3-month multidisciplinary treatment experienced superior symptom improvement compared with patients who only saw a gastroenterologist, according to data presented at Digestive Disease Week.
Gerald J. Holtmann, MD, PhD, of the University of Queensland in Australia, said that functional disorders, like irritable bowel syndrome, present difficulties for physicians, the health care system, and particularly for patients.
“Their quality of life is severely impacted,” he said in his presentation. “We need to be mindful there’s increase morbidity and mortality, not from the condition, but there are problems because of all of the futile tests and interventions which are applied actually can do harm.”
To test the efficacy of a multidisciplinary care approach, researchers recruited 35 patients (mean age 41.3 years, 81% women) with a severe manifestation of a FGID — defined as having symptoms for more than 3 years that impaired quality of life and did not sufficiently respond to previous conventional therapy — and matched them to 35 control patients with a non-severe FGID.
Patients with a severe FGID underwent a standardized assessment and treatment sessions with a GI, general practitioner, psychologist, dietitian and exercise physiologist. Controls received standard care by a GI.
The primary outcome of the study was change in number of items scored moderate and above on the Structured Assessment of Gastrointestinal Symptoms (SAGIS) scale, which is a measurement of 22 GI symptoms scored on a scale of 0 to 4.
Patients in the study had a primary diagnosis of IBS (54.3%), functional dyspepsia (11.4%) or both (34.4%).
Patients in the multidisciplinary care group saw the number of SAGIS items scored moderate and above decrease by 48% compared with a 6% decrease in the control group (P = .001). They also experienced a 36% decrease in total SAGIS score compared with 8% in the control group (P = .001). Additionally, 57% made clinically significant reductions in SAGIS scale compared with 23% in the control group.
Holtmann said their findings showed that an integrated care approach is superior to a standard model of care for patients with severe FGID manifestations.
“However, this is a starting point, and future prospective, randomized clinical trials are required to determine the relative contributions and the doses of the various components required to achieve optimal outcomes and to determine the cost-efficiency of this approach,” he said. – by Alex Young
Reference:
Bray N, et al. Abstract 273. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.
Disclosures: Holtmann reports no relevant financial disclosures. Please see the meeting disclosure index for all other authors’ relevant financial disclosures.
Perspective
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William D. Chey, MD
Irritable bowel syndrome is a symptom-based condition defined by the presence of abdominal pain and altered bowel habits – with patients experiencing diarrhea, constipation, or both.
Given the diverse clinical phenotype, it should come as no surprise that the pathogenesis of IBS is also diverse. Studies over the past 60 years have implicated in a wide range of factors in the pathogenesis of IBS including abnormalities in motility, visceral sensation, brain-gut interactions and more recently, genetics, gut dysbiosis including small intestinal bacterial overgrowth, intestinal permeability, and gut immune activation. Environmental factors including food and stress are important, consistently reported triggers for IBS symptoms.
The clinical and pathophysiologic diversity of IBS explains the marginal clinical response to various medical, diet and behavioral treatments. A treatment that targets serotonin receptors, opiate receptors or chloride channels would be expected to benefit only a subset of patients with IBS and in fact, that is exactly what the available randomized controlled trials (RCT) suggest. Most RCTs of IBS treatments report an overall response rate of less than 60% and a therapeutic gain vs. placebo of 10% to 20%. Despite these facts, treatment of IBS in most developed countries has focused on empiric drug therapy.
Intuitive reasoning would suggest that an integrative approach that addresses multiple potential causes and triggers for IBS symptoms might be more successful, particularly for more complex and severely affected patients, than a strategy that relies on medications alone. At present, such a care model is the exception rather than the rule.
The case control study by Bray et al. provides evidence that such an integrative approach offers greater benefits for IBS patients than traditional therapy. This mirrors our own clinical experience at Michigan Medicine. It would be valuable to more formally evaluate the benefits of an integrative care model in a properly designed and powered RCT.
That said, these data lend support to the importance of non-physician providers, such as GI dietitians and behavioral psychologists, as members of the care team for patients with IBS and other functional GI disorders.
References
Chey WD, et al. JAMA. 2015;313(9);949-958.
Ford AC, et al. Am J Gastroenterol. 2018;113:1-18.
Lenhart A, et al. J Neurogastroenterol Motil. 2018;24:437-451.
Mearin F, et al. Gastroenterol. 2016;150:1393-1407.
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