Symptomatic efficacy of beidellitic montmorillonite in irritable bowel syndrome: a randomized, controlled trial

Montmorillonite: An advanced material with diverse pharmaceutical and medicinal applications

Montmorillonite (MMT) clay is composed of naturally layered silicate. The clays were more popular in the pharmaceutical and other various fields due to their beneficial physicochemical properties viz. non-toxicity, high surface area, efficient adsorption capability, high swellability, high dispersibility, thixotropic behaviour, and cation exchange capacity. Chemically modified clay provides significant opportunities in variety of applications. MMT finds very crucial place in pharmaceutical field owing to its medicinal properties, which may be used to delay the drug release in chronic physiological conditions and the targeted drug release as well. It is also used to improve the dissolution rate of certain drug molecules, which increased the attention of the researchers to explore the MMT for drug delivery applications. MMT clay has been used as pharmaceutical aids viz. suspending agent, lubricant, anticaking agent, diluent, emulsifier, nanocomposites-forming material, and sometimes filler. MMT clay have been investigated in the fabrication of different pharmaceutical formulations viz. hydrogel, films, nanocomposites, and matrix-based systems. MMT has obtained industrial importance due to its adsorption property and also finds use in wastewater treatment. Other than this, MMT also finds applications in cosmetic industry, food industry, and paper industry. Considering the wide applicability of MMT, it is need of an hour to explore the MMT for further commercial exploitation.

Safety and efficacy of purified clinoptilolite-tuff treatment in patients with irritable bowel syndrome with diarrhea: Randomized controlled trial

BACKGROUND

Irritable bowel syndrome (IBS) is a highly prevalent gastrointestinal disorder with poor response to treatment. IBS with predominant diarrhea (IBS-D) is accompanied by abdominal pain as well as high stool frequency and urgency. Purified clinoptilolite-tuff (PCT), which is approved by the Food and Drug Administration for use as a dietary supplement with the brand name G-PUR^®, has previously shown therapeutic potential in other indications based on its physical adsorption capacity.

AIM

To assess whether symptoms of IBS-D can be ameliorated by oral treatment with PCT.

METHODS

In this randomized, placebo-controlled, double-blind pilot study, 30 patients with IBS-D diagnosis based on Rome IV criteria were enrolled. Following a 4-wk run-in phase, 14 patients were randomized to receive a 12-wk treatment with G-PUR^® (2 g three times daily), and 16 patients received placebo. The relief from IBS-D symptoms as measured by the proportion of responders according to the Subject’s Global Assessment (SGA) of Relief was assessed as the primary outcome. For the secondary outcomes, validated IBS-D associated symptom questionnaires, exploratory biomarkers and microbiome data were collected.

RESULTS

The proportions of SGA of Relief responders after 12 wk were comparable in both groups, namely 21% in the G-PUR^® group and 25% in the placebo group. After 4 wk of treatment, 36% of patients in the G-PUR^® group vs 0% in the placebo group reported complete or considerable relief. An improvement in daily abdominal pain was noted in 94% vs 83% (P = 0.0353), and the median number of days with diarrhea per week decreased by 2.4 d vs 0.3 d in the G-PUR^® and placebo groups, respectively. Positive trends were observed for 50% of responders in the Bristol Stool Form Scale. Positive trends were also noted for combined abdominal pain and stool consistency response and the Perceived Stress Questionnaire score. Only 64% in the G-PUR^® group compared to 86% in the placebo group required rescue medication intake during the study. Stool microbiome studies showed a minor increase in diversity in the G-PUR^® group but not in the placebo group. No PCT-related serious adverse events were reported.

CONCLUSION

In this randomized, double-blind, placebo-controlled study, the PCT product, G-PUR^®, demonstrated safety and clinical benefit towards some symptoms of IBS-D, representing a promising novel treatment option for these patients.

Long-term diosmectite use does not alter the gut microbiota in adults with chronic diarrhea

Background

Diosmectite, a natural colloidal clay, has been used worldwide for a number of approved indications, including the treatment of chronic functional diarrhea. Here, we used high-resolution whole metagenome shotgun sequencing to assess the impact of a 5 weeks administration of diosmectite (3 g/sachet, 3 sachets/day) on the fecal microbiota of 35 adults with functional chronic diarrhea.

Results

Gut microbiota was not impacted by diosmectite administration. In particular, richness remained stable and no microbial species displayed a significant evolution. Segregating patients either by diosmectite response (non responder, early responder, late responder) or by nationality (Great-Britain or Netherlands) yielded the same results.

Conclusion

We concluded that no microbiota-related physiological alterations are expected upon long-term treatment with diosmectite.

Trial registration

Clinicaltrials.gov NCT03045926

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-022-02464-7.

Smectite as a Preventive Oral Treatment to Reduce Clinical Symptoms of DSS Induced Colitis in Balb/c Mice

Natural smectites have demonstrated efficacy in the treatment of diarrhea. The present study evaluated the prophylactic effect of a diosmectite (FI5pp) on the clinical course, colon damage, expression of tight junction (TJ) proteins and the composition of the gut microbiota in dextran sulfate sodium (DSS) colitis. Diosmectite was administered daily to Balb/c mice from day 1 to 7 by oral gavage, followed by induction of acute DSS-colitis from day 8 to 14 ("Control", n = 6; "DSS", n = 10; "FI5pp + DSS", n = 11). Mice were sacrificed on day 21. Clinical symptoms (body weight, stool consistency and occult blood) were checked daily after colitis induction. Colon tissue was collected for histological damage scoring and quantification of tight junction protein expression. Stool samples were collected for microbiome analysis. Our study revealed prophylactic diosmectite treatment attenuated the severity of DSS colitis, which was apparent by significantly reduced weight loss (p = 0.022 vs. DSS), disease activity index (p = 0.0025 vs. DSS) and histological damage score (p = 0.023 vs. DSS). No significant effects were obtained for the expression of TJ proteins (claudin-2 and claudin-3) after diosmectite treatment. Characterization of the microbial composition by 16S amplicon NGS showed that diosmectite treatment modified the DSS-associated dysbiosis. Thus, diosmectites are promising candidates for therapeutic approaches to target intestinal inflammation and to identify possible underlying mechanisms of diosmectites in further studies.

A versatile ultrafine and super-absorptive H+-modified montmorillonite: application for metabolic syndrome intervention and gastric mucosal protection

Metabolic syndrome (MetS) includes central obesity, hypertension, insulin resistance, and dyslipidemia and is closely related to nonalcoholic fatty liver disease, atherosclerotic cardiovascular disease (CVD) and type 2 diabetes mellitus, involving multiple causative factors. Current drug therapies for intervention and amelioration of MetS are essential in clinical treatment of metabolic disease. In this report, we proposed an H⁺-modified montmorillonite (H-MMT) using an acid modification method with ultrafine structure and super absorption ability as a potential drug for MetS. Hamsters fed a high-fat diet were orally treated with H-MMT and simvastatin was applied as a control. H-MMT lowered lipids by decreasing intestinal absorption and promoting lipid excretion, subsequently preventing obesity, fatty liver, and hyperlipidemia. Moreover, H-MMT was significantly safer and better tolerated by the liver compared to simvastatin, which was hepatotoxic. In addition, we found that H-MMT had protective effects on gastric mucosal damage. Therefore, this versatile H-MMT provides a potential strategy to effectively improve MetS and provide gastric mucosal protection in clinical applications.

Second Asian Consensus on Irritable Bowel Syndrome

BACKGROUND/AIMS

There has been major progress in our understanding of the irritable bowel syndrome (IBS), and novel treatment classes have emerged. The Rome IV guidelines were published in 2016 and together with the growing body of Asian data on IBS, we felt it is timely to update the Asian IBS Consensus.

METHODS

Key opinion leaders from Asian countries were organized into 4 teams to review 4 themes: symptoms and epidemiology, pathophysiology, diagnosis and investigations, and lifestyle modifications and treatments. The consensus development process was carried out by using a modified Delphi method.

RESULTS

Thirty-seven statements were developed. Asian data substantiate the current global viewpoint that IBS is a disorder of gut-brain interaction. Socio-cultural and environmental factors in Asia appear to influence the greater overlap between IBS and upper gastrointestinal symptoms. New classes of treatments comprising low fermentable oligo-, di-, monosacharides, and polyols diet, probiotics, non-absorbable antibiotics, and secretagogues have good evidence base for their efficacy.

CONCLUSIONS

Our consensus is that all patients with functional gastrointestinal disorders should be evaluated comprehensively with a view to holistic management. Physicians should be encouraged to take a positive attitude to the treatment outcomes for IBS patients.

Effect of a montmorillonite-bentonite-based product on faecal parameters of horses

Free faecal water (fluid excreted separate from normal faeces) is a common problem of unknown origin in horses. Multifactorial causes are assumed. This study assessed the effect of a commercial product (EMP) sold to help support intestinal health of horses, particularly regarding the occurrence of free faecal water. The hypothesis was that water-binding capacity and microbial activity are improved in the large intestine of horses fed EMP. EMP contained montmorillonite-bentonite, whey and extracts from hop and absinthium. Eight adult and healthy horses kept on the same diet and bedding were additionally fed EMP. In a complete crossover study design, all horses participated as control (C) and as test animal receiving EMP (E). Faecal score was assessed. Faecal samples were analysed for pH, ammonia, dry matter content (DM), crude fibre (CF), soxhlet fat (SF), crude protein (CP), crude ash (CA), neutral detergent fibre (NDF), acid detergent fibre (ADF), acid detergent lignin (ADL) and volatile fatty acids (VFAs). None of the assessed parameters measured in the faeces showed a significant treatment effect. This study was conducted in healthy horses without any gastrointestinal disorders. VFA analysis did not show treatment effects. However, apparent higher variability in CP in the faeces of E might be a hint for changes in the intestinal microbiota. Further studies and analysis of additional parameters for example the differentiation of the faecal microbial profile in horses susceptible to free faecal water are necessary to evaluate the effect of EMP.

Ag-carried CMC/functional copolymer/ODA-Mt wLED-treated NC and their responses to brain cancer cells

The subject of this work is synthesis and characterization of novel multifunctional nanocomposite (8/2A-NC) consisting (1) carboxymethyl cellulose (CMC) as a matrix biopolymer and poly (maleic acid-alt-acrylic acid) as a reactive synthetic partner matrix polymer; (2) octadecyl amine montmorillonite (ODA-MMT) reactive organoclay provide intercalated silicate layers structures and aqueous colloidal dispersing medium, and MMT as carriers and targeting agents for anticancer agents in drug delivery systems, respectively. ODA as a intercalated surfactant finely dispersed 8/2A NC and its compatibility with matrix polymers via the interfacial polarization (complexing) and functionalization of matrix polymers by amine (ODA) and carboxylic acids from both the CMC and copolymer; (3) silver nanoparticles (AgNPs) as in-situ generated onto matrix polymers with unique nano-size and morphology parameters was synthesized. Important material science and bioengineering aspects of these investigations included (a) novel approach in synthetic pathways; (b) effects of physical and chemical structural rearrangements; (c) effects of Light Emitting Dioda (LED)-treatment on the FT-IR spectra, XRD reflection parameters, SEM-TEM morphology and nano-size and diameter distribution of AgNPs onto matrix polymers; (d) positive effect of LED-treatment of 8/2A nanocomposite and its response to the MIAPaCa-2 and U87 human brain cancer cell lines were evaluated. Novel 8/2A-NC multifunctional drug consisting unique positive, intercalating and encapsulated core-shell morphology structures, nano-size (5.6 nm) and narrow diameter distribution (94%) of AgNPs onto matrix polymers [silver NPs (0.25%) in 8/2A NC (25%)] with highest volume of contact area compared with used cancer micro-cells show lowest cell viability as an excellent anticancer platform. 8/2A-NC is a novel multifunctional drug with intercalating and encapsulated core-shell morphology structures consisting of positively charged, non-randomly distributed AgNPs with a large contact area and low diameters (5-6 nm). The anticancer properties of (This factor is not conformed experimentally in work) this drug can be explained by the following structural factors: 8/2A-NC contains a combination of active sites from protonated hydroxyl, carboxyl and amine groups; Ag⁺-cations and ODA-MMT with high physical and chemical surface areas. We suggest this material be further explored for anti-cancer testing.

Microbiome Remodeling via the Montmorillonite Adsorption-Excretion Axis Prevents Obesity-related Metabolic Disorders

Obesity and its related metabolic disorders are closely correlated with gut dysbiosis. Montmorillonite is a common medicine used to treat diarrhea. We have previously found that dietary lipid adsorbent-montmorillonite (DLA-M) has an unexpected role in preventing obesity. The aim of this study was to further investigate whether DLA-M regulates intestinal absorption and gut microbiota to prevent obesity-related metabolic disorders. Here, we show that DLA-M absorbs free fatty acids (FFA) and endotoxins in vitro and in vivo. Moreover, the combination of fluorescent tracer technique and polarized light microscopy showed that DLA-M crystals immobilized BODIPY® FL C16 and FITC-LPS, respectively, in the digestive tract in situ. HFD-fed mice treated with DLA-M showed mild changes in the composition of the gut microbiota, particularly increases in short-chain fatty acids (SCFA)-producing Blautia bacteria and decreases in endotoxin-producing Desulfovibrio bacteria, these changes were positively correlated with obesity and inflammation. Our results indicated that DLA-M immobilizes FFA and endotoxins in the digestive tract via the adsorption-excretion axis and DLA-M may potentially be used as a prebiotic to prevent intestinal dysbiosis and obesity-associated metabolic disorders in obese individuals.

Application of montmorillonite in bentonite as a pharmaceutical excipient in drug delivery systems

Montmorillonite is a multifunctional clay mineral and a major component of bentonite. Montmorillonite has been used in various industrial and pharmaceutical fields due to its unique characteristics, which include swelling and adsorption. The high adsorption capacity of montmorillonite contributes to increase drug entrapment and sustained-release of drugs. Montmorillonite generally sustains drug release in many formulations by strongly adsorbing to the drug. In addition, montmorillonite enhances the dissolution rate and bioavailability of hydrophobic drugs. Moreover, montmorillonite was applied to form composites with other polymer-based delivery systems. Thus, montmorillonite could be applied to formulate diverse drug delivery systems to control and/or improve the pharmaceutical properties of drugs, including solubility, dissolution rate, and absorption. In this review, perspectives of applying montmorillonite as a pharmaceutical excipient in drug delivery systems are discussed.

Irritable bowel syndrome with constipation: a European-focused systematic literature review of disease burden

OBJECTIVE

To conduct a systematic literature review to assess burden of disease and unmet medical needs in patients with irritable bowel syndrome (IBS) with constipation (IBS-C), with a focus on five European countries (France, Germany, Italy, Spain, UK).

METHODS

MEDLINE, EMBASE, and grey literature searches were carried out using terms for IBS and constipation, to identify studies reporting epidemiological, clinical, humanistic, or economic outcomes for IBS-C, published between 2000 and 2010.

RESULTS

Searches identified 885 unique abstracts and 33 supplementary articles, of which 100 publications and six grey literature sources met the inclusion criteria. Among patients with IBS, the prevalence estimates of IBS-C ranged from 1 to 44%. Co-morbid conditions, such as personality traits, psychological distress, and stress, were common. Patients with IBS-C had lower health-related quality-of-life (HRQoL) compared with the general population, and clinical trials suggested that effectively treating IBS-C improves HRQoL. The European societal cost of IBS-C is largely unknown, as no IBS-C-specific European cost-of-illness studies were identified. Two cost analyses demonstrated the substantial societal impact of IBS-C, including reduced productivity at work and work absenteeism. Guidelines offered similar recommendations for the diagnosis and management of IBS; however, recommendations specifically for IBS-C varied by country. Current IBS-C treatment options have limited efficacy and the risk:benefit profile of early 5-HT(4) agonists restricts clinical use.

CONCLUSIONS

This systematic review indicates a clear need for European-focused IBS-C burden-of-disease and cost-of-illness studies to address identified evidence gaps. There is a need for new therapies for IBS-C that are effective, well tolerated, and have a positive impact on HRQoL.

Uliginosin B presents antinociceptive effect mediated by dopaminergic and opioid systems in mice

Previous studies have shown that uliginosin B inhibits dopamine reuptake in rat brain. This compound occurs in Hypericum polyanthemum and H. caprifoliatum for which was reported to have antinociceptive effect sensitive to naloxone. The aim of this study was to assess the antinociceptive effect of uliginosin B and to evaluate the involvement of opioid and dopaminergic receptors activation. Uliginosin B presented antinociceptive effect in hot-plate and abdominal writhing tests, in mice, at doses that did not impair the motor coordination (15 mg/kg, i.p.). Uliginosin B in high dose (90 mg/kg, i.p.) presented ataxic effect in the rotarod apparatus. These effects seem to be mediated by distinct receptors since the effect on the hot-plate was completely abolished by naloxone and sulpiride, but it was unaffected by SCH 23390. On the other hand, the motor impairment induced by uliginosin B was completely prevented by naloxone and partially prevented by sulpiride and SCH 23390. However, the receptors' activation appears to be indirect since uliginosin B did not bind to opioid and dopaminergic receptors. Thus, uliginosin B effects probably are due to its ability to inhibit monoamine reuptake with consequent activation of dopamine receptors and indirect stimulation of opioid system.

Clay jojoba oil facial mask for lesioned skin and mild acne--results of a prospective, observational pilot study

BACKGROUND

External application of clay facial masks is a cosmetic procedure generally used to reduce skin lesions and to improve overall skin condition.

OBJECTIVE

Collecting pilot data about self-treatment with clay jojoba oil masks on participants with acne-prone, lesioned skin and acne.

METHODS

Open, prospective, observational pilot study: Participants received written information, instructions, and questionnaires without direct contact with the study physician. For 6 weeks, they applied the masks 2-3 times per week. The primary outcome is the difference of skin lesions: baseline vs. after 6 weeks.

RESULTS

194 participants (192 female, 2 male, mean age (± SE) (32.3 ± 0.7 years) returned questionnaires and diaries. 133 of these participants returned complete and precise lesion counts (per-protocol (PP) collective). A 54% mean reduction in total lesion count was observed after 6 weeks of treatment with clay facial mask. Both inflammatory and non-inflammatory skin lesions were reduced significantly after treatment compared to baseline: Median counts (MC) of pustules per affected participant were reduced from 7.0 ± 0.9 to 3.0 ± 0.5 (mean individual reduction (MIR) = 49.4%), the MC of the papules from 3.5 ± 2.2 to 1.0 ± 0.4 (MIR = 57.3%), the MC of cysts from 2.0 ± 0.8 to 0.5 ± 0.4 (MIR = 68.6%) and the MC of comedones from 26.5 ± 6.3 to 16.0 ± 4.0 (MIR = 39.1%). DLQI-average score decreased from 5.0 ± 4.5 (mean ± SE) before to 2.1 ± 2.8 after treatment.

CONCLUSIONS

The present study gives preliminary evidence that healing clay jojoba oil facial masks can be effective treatment for lesioned skin and mild acne vulgaris.

[Irritable bowel syndrome: dietary and pharmacological therapeutic options]

In irritable bowel syndrome, the main objectives of the treatment are the relief of abdominal pain then the improvement of bowel disturbances. Spasmolytic agents, or clays remain routinely the first line pharmacological options. The efficacy of dietary recommendations is not validated in most of the cases while dietary fibers, mainly insoluble fibers, may even worsen abdominal discomfort. In C-IBS, osmotic laxatives or macrogol are effective to improve colonic transit while loperamide and also colestyramine can be prescribed to reduce the number of stools of D-IBS patients. When the first line treatment fails to improve symptoms, antidepressants (tricyclic rather than SSRs) can be prescribed at lower doses than that recommended for depression. In meta-analysis, the odds ratio for pain relief varies from 2 to 4 and strongly depends on the patient's compliance to the treatment. Probiotics, pregabalin and even antibiotics (i.e neomycin, metronidazole or rifaximin), are possible new therapeutic options. Few clinical trials suggest that ramosetron (a new 5HT3 antagonist), octreotide, melatonin, or lidocain could be also discussed in the future. A non pharmacological therapeutic approach has to be considered, particularly in patients with severe symptoms, in combination with pharmacological treatment.

Inhibition of intestinal absorption of cholesterol by surface-modified nanostructured aluminosilicate compounds

The aim of this work was to assess the ability of aqueous suspensions of surface-modified nanostructured aluminosilicate (NSAS) compounds to reduce the intestinal absorption of cholesterol in a rat model. The rats were divided into 10 treatment groups which included several NSAS compounds at various doses, ezetimibe at 10 mg/kg, stigmastanol at 50 mg/kg, and normal saline. All compounds and controls were independently administered by oral gavage and then a mixture of [(3)H]cholesterol and cold cholesterol in 10% Intralipid(R) was immediately administered orally to the animals. Systemic blood was sampled and the concentration of cholesterol in plasma was determined by means of radioactivity. Protonation of NSAS using an ion-exchange column resulted in significant inhibition of cholesterol absorption relative to the control group (31.5% and 38.6% reduction in absorption of cholesterol for 50 and 100 mg/kg doses, respectively). Other surface-ion modifications of NSAS compounds did not show significant effect on intestinal cholesterol absorption. The inhibition of cholesterol absorption by ezetimibe was superior and by stigmastanol was equal to the effect of protonated NSAS in the doses investigated in this study. In conclusion, protonated NSAS material seems to inhibit significantly the intestinal absorption of dietary cholesterol in a rat model.

Treatment of irritable bowel syndrome using complementary and alternative medicine

The therapeutic objectives for irritable bowel syndrome (IBS) patients are to improve their functioning in society. Accordingly, recommended management is to develop a logical strategy including a positive diagnosis, consideration of the patient's agenda and emotional state, critical appraisal of the efficacies of various drugs and a graded therapeutic response. Unfortunately, none of the currently available drugs (e.g. antispasmodics, antidiarrheals, osmotics, cathartics, bulking agents, tranquilizers, sedatives) are globally effective in treating all IBS symptoms, and the advanced receptor-targeted drugs are not always successfully and safely marketed. Consequently, more than half of patients may seek complementary and alternative medicine (CAM) to treat the annoying bowel symptoms. Physicians have considered these CAM measures to have an "enhanced placebo effect". For example, many herbal medicine and plant products are globally used to treat IBS, whereas their efficacies are often inconclusive because of small sample sizes, inadequate data analyses and lack of standardized preparations. Meta-analyses do not establish their true efficacy. Acupuncture has long been employed by patients themselves to treat functional gastrointestinal disorders with satisfactory response, but its effect on IBS does not seem to be promising. Peppermint oil, melatonin and clay-like materials are effective in treating some IBS symptoms, while their true pharmacology remains enigmatic. In conclusion, IBS treatment is usually tailored to the individual's manifestations, ranging from reassurance to psychotherapy. Apart from conventional medications, CAM may be considered individually as a supplement or alternative to treat IBS patients that is at least equal in effect to placebo if patients do not exhibit any intolerable or serious side effects.

Efficacy of dioctahedral smectite in treating patients of diarrhea-predominant irritable bowel syndrome

BACKGROUND AND AIM

Dioctahedral smectite (DS) is natural adsorbent clay useful in treating acute diarrhea. The aim of this study was to determine DS efficacy on patients with diarrhea-predominant irritable bowel syndrome (D-IBS in a phase III-, 8-week-randomized, double-blind, placebo-controlled trial.

METHODS

The 104 patients who met the D-IBS Rome II criteria were randomized to receive either DS (n = 52) or placebo (n = 52) treatment for 8 weeks (three sachets daily). The primary efficacy endpoint was the changes of the visual analog scale (VAS) score of IBS overall disorder and pain/discomfort-related symptoms after treatment on days 28 and 56, respectively. Other outcome measures included improvement of bowel movement disorders. The therapeutic global response was assessed by the patients and investigators at each visit, as was drug safety.

RESULTS

Both treatments diminished overall disorder at each visit (P < 0.01), with respect to primary efficacy. This effect was further observed in DS-treated patients on day 56 (P = 0.0167). Placebo had no effect on the VAS score of pain/discomfort at any visit, whereas DS improved this score on days 28 and 56, respectively (P < 0.05). DS and placebo similarly diminished bowel disorders at each visit; however, only DS improved abdominal bloating (P < 0.01). The global therapeutic responses evaluated by the patients and investigators were similarly distributed. The study drug was well tolerated during the 8-week period.

CONCLUSION

DS seems acceptable to treat D-IBS patients, particularly for pain-related symptoms.

Syndrome de l'intestin irritable: options thérapeutiques actuelles

Relieving abdominal pain is the principal treatment objective for patients with irritable bowel syndrome. No single drug stands out in the treatment strategy for this illness. Antispasmodics, magnesium aluminum silicates, and alverine citrate drugs all remain initial options for treatment, although their prescription is impeded by the fact that an increasing number are no longer approved for reimbursement. Increased dietary fibers often have a harmful effect on symptoms. Some patients are probably intolerant to some foods but there is no satisfactory proof on which to base a restrictive diet. Improved knowledge of the pathophysiology of irritable bowel syndrome has made it possible to diversify treatments that act first on one of the key pathophysiologic elements, visceral hypersensitivity. Antidepressants (especially tricyclics) can be used at low doses. Among the serotonergic drugs, serotonin 5-HT4 receptors agonists (tegaserod) may be available soon, but the development of 5-HT3 antagonists (alosetron, cilansetron) has been stopped for safety reasons (ischemic colitis and severe constipation). Non-drug options such as hypnosis, psychotherapy, relaxation, or yoga, may also be proposed to some patients. Probiotics are a possible treatment in the future.

Systematic review: the efficacy of treatments for irritable bowel syndrome--a European perspective

BACKGROUND

Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit.

AIM

To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe. The safety and tolerability of these therapies are the subject of an accompanying review.

METHODS

A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome.

RESULTS

There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised.

CONCLUSIONS

There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.

Systematic review: the safety and tolerability of pharmacological agents for treatment of irritable bowel syndrome--a European perspective

AIM

To use an evidence-based approach to evaluate the safety and tolerability of the treatments available for irritable bowel syndrome (IBS), or in clinical development, in Europe. A separate review appraises the evidence for the efficacy of these therapies.

METHODS

A literature search (for 1980 to 2005) was completed for all relevant clinical trial data and other articles which included safety information on the use of pharmacological IBS therapies. Clinical trials were scored according to the level of safety information, and adverse event incidence reported when possible.

RESULTS

The tolerability of many of the agents used to treat IBS in Europe is poorly understood. However, serotonergic agents, such as tegaserod and alosetron, which are currently unavailable in Europe, have undergone rigorous assessment in IBS and their benefits have been established. Following initial marketing of alosetron for use in patients with IBS with diarrhoea, concerns about severe constipation and ischaemic colitis resulted in restriction of its use to women with severe IBS symptoms. This highlights the importance of post-marketing surveillance and post-marketing studies in refining the therapeutic indication of new IBS therapies, which will help to identify appropriate recipients for the drug and establish the impact of adverse reactions in clinical practice.

CONCLUSIONS

There is a significant lack of data on the safety and tolerability of the therapies currently used routinely to treat IBS in Europe. The newer agents have undergone rigorous assessment, such that their benefits and risks in treating IBS are established. Defining their place among the spectrum of available therapies remains challenging when the benefits and risks of the older treatments are so poorly characterized.