ACG develops guidelines for treatment of IBS
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The American College of Gastroenterology developed clinical guidelines for the treatment of irritable bowel syndrome.
“We believe that the information provided in this guideline will help guide both practitioners and researchers for years to come,” Brian E. Lacy, PhD, FACG, from the Mayo Clinic in Jacksonville, Florida, and colleagues said in recommendations published in the American Journal of Gastroenterology. “However, as this extensive project evolved, we recognized that there are still significant gaps in our knowledge. Future research is needed to better understand the role of the gut microbiome in patients with IBS and to understand the genesis of visceral pain.”
Lacy and colleagues used Grading of Recommendations, Assessment, Development and Evaluation methodology to evaluate 25 clinically important questions. Of these, nine questions focused on diagnostic testing and 16 questions focused on therapeutic options.
Among the 25 recommendations for IBS from the ACG are:
- Serologic testing should be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.
- Fecal calprotectin, fecal lactoferrin and C-reactive protein should be checked in patients without alarm features and with suspected symptoms of IBS and diarrhea to rule out inflammatory bowel disease
- Routine stool testing should not be performed for enteric pathogens in all IBS patients.
- Routine colonoscopy should not be performed in patients with IBS symptoms aged younger than 45 years without warning signs.
- A positive diagnostic strategy vs. a diagnostic strategy of exclusion should be used for patients with IBS symptoms to improve time to initiate appropriate therapy and cost-effectiveness.
- Do not test for food allergies and sensitivities unless patients have reproducible symptoms concerning a food allergy.
- Anorectal physiology testing should be performed in patients with IBS and symptoms that may suggest a pelvic floor disorder and refractory constipation.
- Anti-spasmodics available in the United States should be used to treat global IBS.
- Peppermint may be used to provide relief of global symptoms.
- Mixed opioid agonists/antagonists should be used to treat global IBS-D symptoms.
- A fecal transplant should not be used for the treatment of global IBS symptoms.
“Additional statements and information regarding diagnostic strategies, specific drugs, doses and duration of therapy can be found in the guideline,” the authors wrote.
Perspective
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Carine Bou-Abboud Matta, MD
IBS is one of the most common diagnoses in outpatient gastroenterology clinics, however guidelines for diagnosis and treatment were lacking. The first ACG guidelines for IBS created a paradigm shift in the diagnosis, moving from a diagnosis of exclusion to that of a positive diagnostic strategy. According to the new guidelines, the diagnosis of IBS should rely on a detailed history, physical examination and minimal diagnostic testing, primarily serologic testing for celiac disease and biomarkers for inflammatory bowel disease. Studies that looked at more invasive diagnostic testing did not significantly change the preliminary diagnosis. Most notably, it recommends against routine colonoscopy in the absence of alarm symptoms, arguably the most expensive diagnostic test and most frequently ordered for patients with IBS.
The new guidelines also focus on IBS treatment. They recommend against antispasmodics, probiotics, PEG products, and bile acid sequestrants, which are frequently prescribed by clinicians for this patient population. In contrast, recommendations support the use of fiber, low FODMAP diet, peppermint, chloride channel activators and guanylate cyclase activators in IBS-C, and rifaximin in IBS-D. However, the application of these recommendations is limited in clinical practice as there is a lack of insurance coverage for these drugs and adherence to a strict low FODMAP diet is challenging for patients.
Further studies are needed to better understand the intricate gut-brain interaction and potential therapeutic options. Despite these limitations, these guidelines provide an excellent starting point to understanding a complex process and can be used as a guide for clinicians to help tailor both diagnostic strategy and therapy of IBS.
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