New Therapies to Ease the Burden of IBS
Irritable bowel syndrome (IBS) has effects far beyond gastrointestinal symptoms. It is one of the most commonly diagnosed chronic gastrointestinal disorders, and occurs most often in patients under age 50. It is characterized by abdominal pain and bowel dysfunction—diarrhea (IBS-D), constipation (IBS-C), or alternating periods of both (mixed—IBS-M). In 40 to 60 percent of cases, IBS is accompanied by psychological disorders such as depression or anxiety.
Patients with IBS have greater occurrences of somatic symptoms (that is, having extreme anxiety about the physical symptoms of IBS, but not actually experiencing them) than patients who don’t have IBS, but who have GI symptoms. To date, there is no cure for IBS; treatment aims at alleviating patient symptoms. An update on pharmacologic and nonpharmacologic interventions for IB was published in the American Journal of Nursing, June 2017. The review evaluated 83 studies in 41 countries.
Possible Underlying Causes. Physiologic and psychological variables have been suggested as possible causes/factors in IBS:
- GI dysmotility—abnormal movement of food, nutrients, and waste through the digestive tract
- Inflammation
- Visceral hypersensitivity—experiencing intense pain in the inner organs (viscera)
- Altered intestinal microbiota
- Diet
- Genetic predisposition
- Stress exposure (including early life events)
However, the exact mechanisms that lead to IBS symptoms still are not fully understood. What is known is that as recently as 2010 (the most recent data available) there were more than two million diagnoses in a variety of settings (office, emergency department, hospital outpatient visits), resulting in reduced quality of life, lost productivity, and direct medical costs. And patients still report inadequate care and support from health care providers. In addition, studies report adverse effects on the quality of life of domestic partners of patients with IBS, most likely because of the burden of care that falls to them.
Stress and Gut/Brain Axis. Risk of developing IBS is increased in people with a greater number of life stressors, a tendency toward panic or other anxiety syndromes, and previous infectious gastroenteritis. Researchers call this connection the brain-gut axis—the endocrine, neural, and neuroimmune pathways that enable communication between the gut, central nervous system, enteric nervous system, autonomic nervous system and the hypothalamic-pituitary-adrenal axis.
Disturbances in the brain-gut axis have been identified in patients with IBS. Compared with healthy control participants, patients with IBS show differences in central processing mechanisms of the brain, for example in connectivity and functional response. Unfortunately, the underlying mechanisms are not yet understood.
Pharmacologic Interventions. Interventions focus on the dominant bowel symptom—diarrhea (IBS-D) or constipation (IBS-C) or mixed (IBS-M) and abdominal pain. Eleven pharmaceutical agents or classes of drugs are used to treat IBS: linaclotide (Linzess), lubiprostone (Amitiza), eluxadoline (Viberzi), polyethylene glycol laxatives (Miralax, Glycolax), rifaximin (Xifaxan), alosetron (Lotronex), loperamide (Imodium), tricyclic antidepressants (Elavil), selective serotonin reuptake inhibitors (Prozac, Zoloft) and antispasmodics (Atropine, Bentyl), and plecanatide (Trulance), approved in January 2017.
Therapies were rated very low, low, moderate, or high, and had “strong” or “weak” recommendations. Only two received strong recommendations—linaclotide and lubiprostone, which increase intestinal fluid secretion, increasing motility and stool passage.
Non-Pharmacologic Interventions. Dietary manipulation, exercise, mind-body therapies, fiber, probiotics, prebiotics, peppermint oil, and hypnotherapy, among others, were investigated for interventions. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy were found beneficial. Others treatments included multicomponent psychological therapy, dynamic psychotherapy, and hypnotherapy.
Dietary modifications: Patients with IBS are more likely to have adverse reactions to food, including gluten, lactose, fermentable oligosaccharides, disaccharides, monosacchaarides, and polyols (FODMAPS—a diet low in carbohydrates), as well as fructose malabsorption. Exclusion diets have been used, with mixed results, although a six-week gluten-free diet has shown to improve symptom severity in patients with IBS-D. Patients also experienced significant improvements in anxiety, depression, fatigue and quality of life. A low-FODMAPS diet also was shown to improve abdominal and bowel symptoms in some patients. Soluble fiber supplementation also had beneficial effects on overall IBS symptoms. Use of probiotics containing Bifidobacterium breve, Bifidobacterium longum or Lactobacillus acidophilus also was found beneficial, though more research is necessary, investigators say.
Fecal microbiota transplantation (FMT): FMT replaces or repairs the native gut microbiota with a new community of gut microorganisms, unlike probiotics which aim to alter the native gut microbiota. The procedure is not yet in widespread use, and researchers say randomized controlled trials are needed to confirm its safety and efficacy. (It has been used with some success to treat clostridium difficile infection.)
Traditional Chinese medicine: Acupuncture and moxibustion have been considered potential treatments for IBS. Moxibustion is the application of heat to the body’s meridians (as acupuncture uses needles applied to the meridians). Results are mixed.
Comprehensive self-management: A nine-session, nurse-delivered, comprehensive self-management intervention that involved cognitive behavioral strategies, diet, relaxation, and education was found to significantly improve GI symptoms and quality of life compared with usual care. The long-term benefits extended out to three-, six-, and 12-month followup; 94 percent of participants were found to incorporate these strategies into their lives one year after their last session.
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