Friday, August 15, 2014

Experts Issue Guidelines for Treating Irritable Bowel Syndrome

Newly released guidelines for the treatment of irritable bowel syndrome and a type of constipation known as chronic idiopathic constipation reveal a number of proven treatments for those two common conditions.

“There’s a greater variety of approaches which reflect a greater understanding of the disorders,” said guidelines co-author Dr. Eamonn Quigley, chief of the division of gastroenterology and hepatology at Houston Methodist Hospital.

“We now have a better opportunity to improve the lives of our patients,” Quigley said.

The guidelines are published in the August issue of the American Journal of Gastroenterology.

An estimated 5 to 15% of the world’s population has irritable bowel syndrome, a condition that can cause symptoms such as abdominal pain, diarrhea or constipation, cramping and bloating, and gas. It can affect people at any age but is especially common when people are in their 20s and 30s, Quigley said.

The condition can be difficult to diagnose because other conditions share the same symptoms. Unlike other conditions, however, there’s no specific diagnostic test for irritable bowel syndrome, he noted. Physicians must rely purely on symptoms to make the diagnosis.

The new guidelines, released this week by the American College of Gastroenterology, say there’s evidence to support the following treatments for irritable bowel syndrome:
• Fiber (psyllium especially when compared to bran)
• Probiotics
• An antibiotic called rifaximin (Rifagut)
• Medications known as linaciotide (Linzess) and lubiprostone (Amitiza)

The irritable bowel syndrome guidelines also say that research has boosted the case for using antidepressant medications and psychological therapy.

Probiotics are a hot topic in medicine. Quigley said research supports their use, but it’s not clear which ones are best. “We need more studies comparing doses and preparations, and there hasn’t been a lot of that done.” He said. Still, probiotics are safe and patients tolerate them well, he noted.

However, the guidelines indicate that there’s not enough evidence to support the use of prebiotics (components of food that can’t be digested and promote healthy bacteria) and symbiotics (products that combine probiotics and probiotics). Dr. William Chey, a gastroenterologist and professor of medicine at the University of Michigan, agreed that it’s difficult to decide which probiotics product to recommend.

As for the diet, Quigley said there’s some evidence that gluten-free diets and so-called “FODMAP” diets can help reduce symptoms of irritable bowel syndrome. Chey said the guideline slightly understate the value of treatments that involve changing diet since there’s evidence that “diet plays a role in the development of the condition and has a role in treatment.”

There are some positive steps here. Most important, there is a shift away medication toward supplementation, diet, and lifestyle. I agree with the use of probiotics and that picking the right probiotic is difficult. It really is not a matter of dose or preparation, although the probiotics must be viable. It is matching the probiotics to the patient and that is dependent or diet, geography, and genetics. We really don’t have all the answers to those questions yet, but we are getting closer.

My biggest issue is conceptual – the treatment is still based on a diagnosis and medicine struggles with IBS because there is are no diagnostic tests to rely on. Rather, IBS is a diagnosis based solely on symptoms and the elimination of other similar conditions like Crohn’s Disease and ulcerative colitis. In my world, these diseases are all under the umbrella of dysbiosis. They manifest in different fashions with autoimmune factors or bleeding, but the underlying cause of all these conditions is alteration of the microbiome of the gut.

Obviously, I believe that the use of antibiotics is contraindicated. Antibiotics are often the cause of dysbiosis in the first place. The recommendation for psyllium and against prebiotics also shows a basic lack of understanding biochemistry in the body. Psyllium is insoluble fiber and probiotics are soluble fiber. Both provide bulk to bowel, but the soluble fiber actually feed the healthy bacteria. In fact, I often choose a prebiotic over a probiotic because it is so difficult to choose the right probiotic. It is better to feed the existing probiotics than introduce a new probiotic that may not be beneficial to the patient.

Finally, probiotics are not always safe and well tolerated. All of them stimulate the GALT (gut associated lymphatic tissue), even if the probiotic is dead when ingested. That stimulation is not always beneficial and can even create an autoimmune response.

While gastroenterology is moving in the right direction, the basic concepts of what constitutes a healthy digestive tract must be incorporated into both the assessment and treatment process.

Source: NIH (National Institutes of Health) -Friday, August 8, 2014

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