Clinical trial: renzapride therapy for constipation-predominant irritable bowel syndrome--multicentre, randomized, placebo-controlled, double-blind study in primary healthcare setting

Review Article: Surrogate Endpoints to Assess Treatment Efficacy in Disorders of Gut-Brain Interaction of Lower Gastrointestinal Tract

BACKGROUND

Surrogate endpoints such as laboratory parameters that are not direct measurements of, but predict, clinical benefit are approved by regulatory agencies for initial proof of efficacy. No surrogate endpoints are approved for disorders of gut-brain interaction.

AIM

To assess the correlation of scintigraphic colonic transit (CT) with response rates according to patient-reported symptom-based endpoints (composite/global symptoms, abdominal pain or stool frequency/consistency) in irritable bowel syndrome (IBS) or chronic idiopathic constipation (CIC).

METHODS

We reviewed available data from, randomised controlled trials (RCTs) reporting effects on CT at 24 h and 48 h with drug versus placebo and extracted the difference in the proportions responding to drug or placebo, using rates from individual RCTs or from meta-analyses when more than one RCT existed for a drug. We analysed associations between differences (drug vs. placebo) in CT and in response rates using Spearman correlation. Additional analyses of CT at 24 h with composite/global symptom or pain endpoints were performed with exclusion of alosetron (the only drug slowing CT).

RESULTS

CT at 24 h correlated significantly with composite/global symptom endpoints (Rs = -0.755, p = 0.021). CT correlated with stool frequency or consistency (at 24 h, Rs = 0.506, p = 0.074; at 48 h, Rs = 0.631, p = 0.026). CT at 24 h did not correlate with abdominal pain (Rs = -0.054, p = 0.843). With the exclusion of alosetron data, CT at 24 h was non-significantly correlated with the composite/global symptom endpoint (Rs = -0.667, p = 0.073), but not with abdominal pain (Rs = 0.377, p = 0.419).

CONCLUSION

Scintigraphic CT measurement fulfils the expectation of a surrogate endpoint for symptom-based outcomes, particularly in IBS-D or IBS-C and CIC.

The placebo response rate in pharmacological trials in patients with irritable bowel syndrome: a systematic review and meta-analysis

BACKGROUND

Clinical trials in irritable bowel syndrome are associated with high placebo response rates. We aimed to identify the magnitude of the placebo response and the contributing factors to this occurrence.

METHODS

We did a systematic review and meta-analysis with a search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials between April 1, 1959, and April 30, 2020. We included all randomised controlled trials that compared an active pharmacotherapeutic agent with placebo and had a dichotomous outcome of response to therapy (in terms of global improvement or improvement in abdominal pain) in adults (aged ≥18 years) with irritable bowel syndrome. Exclusion criteria were trials reporting on treatment satisfaction as a dichotomous outcome of response to therapy or clinician-reported outcomes and a treatment duration of less than 4 weeks. Our main outcome was identification of the magnitude of the pooled placebo response rate for the following endpoints: global improvement, abdominal pain, and US Food and Drug Administration (FDA) endpoints. We extracted information from published reports and pooled proportions through meta-analysis with random effects. The study was registered with PROSPERO, CRD42020170908.

FINDINGS

Of the 6863 publications identified, 70 articles describing 73 randomised controlled trials were included in our analysis. The pooled placebo response rate was 27·3% (95% CI 24·3-30·9) using the global improvement endpoint, 34·4% (31·2-37·8) using the abdominal pain endpoint, and 17·9% (15·2-21·0) using the composite FDA endpoint responder definition, all with substantial heterogeneity between the trials. Studies published before 2006, and those done in Europe, with a parallel design, a run-in period of 2 weeks or less, a dose schedule of three times a day or more, or a smaller sample size of the control group were significantly associated with an increased pooled placebo response rate.

INTERPRETATION

More than a quarter of patients with irritable bowel syndrome had a placebo response in terms of global improvement, with multiple associated moderators. We recommend future trials apply a run-in period of at least 2 weeks and dose once or twice a day to minimise the placebo response rate.

FUNDING

None.

Sex-Gender Differences in the Effectiveness of Treatment of Irritable Bowel Syndrome: A Systematic Review

Background

In recent years, research on sex-gender differences in health care has increasingly recognized that men and women differ in the way symptoms occur, in risk factors for certain conditions and in the way they respond to the same treatment. A disease that is known to often present differently in women and men is irritable bowel syndrome (IBS). Given the difference in prevalence, predominant symptoms and possible other pathophysiology, it is conceivable that a difference in treatment effectiveness in men and women is a discovery waiting to be found.

Purpose

To determine whether there are differences in treatment effectiveness between men and women with irritable bowel syndrome.

Materials and Methods

We searched on PubMed and EMBASE, selecting randomized controlled trials comparing IBS treatment in men and women over 18 years old. One researcher performed the inclusion process, and two researchers independently performed a quality assessment. A descriptive analysis was conducted.

Results

Twelve studies, randomizing 1847 men and 3562 women, were included in this review. Treatment with serotonin antagonist alosetron, treatment with ibodutant and crofelemer and adding cognitive behavioral therapy to medical treatment found significant differences between men and women in favor of effectiveness towards women in either satisfactory relief of overall IBS symptoms or percentage of pain-free days.

Conclusion

Sex-gender can be a determining factor in the effectiveness of IBS treatment. Due to the limited number of studies per treatment option, no recommendations can be made on the choice of a specific treatment. It is clear, however, that so as not to miss beneficial treatment options for either sex, the inclusion, analysis and description of data on the basis of sex is of the utmost importance.

New therapeutic perspectives in irritable bowel syndrome: Targeting low-grade inflammation, immuno-neuroendocrine axis, motility, secretion and beyond

Irritable bowel syndrome (IBS) is a chronic, recurring, and remitting functional disorder of the gastrointestinal tract characterized by abdominal pain, distention, and changes in bowel habits. Although there are several drugs for IBS, effective and approved treatments for one or more of the symptoms for various IBS subtypes are needed. Improved understanding of pathophysiological mechanisms such as the role of impaired bile acid metabolism, neurohormonal regulation, immune dysfunction, the epithelial barrier and the secretory properties of the gut has led to advancements in the treatment of IBS. With regards to therapies for restoring intestinal permeability, multiple studies with prebiotics and probiotics are ongoing, even if to date their efficacy has been limited. In parallel, much progress has been made in targeting low-grade inflammation, especially through the introduction of drugs such as mesalazine and rifaximin, even if a better knowledge of the mechanisms underlying the low-grade inflammation in IBS may allow the design of clinical trials that test the efficacy and safety of such drugs. This literature review aims to summarize the findings related to new and investigational therapeutic agents for IBS, most recently developed in preclinical as well as Phase 1 and Phase 2 clinical studies.

Efficacy and safety of enteric coated capsules of anise oil to treat irritable bowel syndrome

ETHNOPHARMACOLOGICAL RELEVANCE

Anise is a well-recognized plant in Traditional Persian Medicine (TPM) sources. Anise oil has been suggested for the treatment of bowel disorders in Persian medical textbooks. Based on TPM scholars, this ingredient has a favorable effect on gastrointestinal diseases. We did this trial to determine the efficacy and safety of enteric coated capsules of anise oil for clinical symptoms of irritable bowel syndrome (IBS).

METHODS AND MATERIALS

This three-armed double-blind clinical trial was carried out from August 2014 to February 2015. 120 patients were divided into three groups by block randomization: AnisEncap, placebo and Colpermin®. Patients in each group received 3 similar capsules per day for 4 weeks. The primary outcome was measured as a visual analogue scale (VAS) score, and the secondary outcome was assessed with an IBS-quality of life questionnaire. Chi-squared tests were used for categorical variables and t-tests to compare continuous variables.

RESULTS

There were no significant differences in demographic characteristics among the three groups. According to intention-to-treat sample analysis, 75% of patients in the treatment group, 35% in the placebo group and 52.5% in active control group were free from IBS symptoms (P<0.001). The effectiveness of AnisEncap in improving IBS symptoms (abdominal discomfort or pain, bloating, diarrhea, constipation severity, difficulty in defecation, gastroesophageal reflux, headache, tiredness, overall satisfaction and quality of life) was significantly greater than placebo or Colpermin® after the 4-week treatment period and the 2-week follow-up period (P<0.0001). The number needed to treat for enteric coated capsules of anise oil was 4, which indicated significantly superior efficacy compared to the other two groups (P<0.001).

CONCLUSION

The effectiveness of AnisEncap was superior to that of placebo or Colpermin® in patients with IBS. Further studies are suggested to find the main mechanism of action of anise oil in this regard.

Acute and subchronic toxicities of QX100626, a 5-HT4 receptor agonist, in rodents and Beagle dogs

Serotonin 5-hydroxytryptamine 4(5-HT4) receptor agonists have been widely prescribed as a prokinetics drug for patients with gastro-esophageal reflux disease and functional dyspepsia. QX100626, one of the 5-HT4 receptor agonists, has been studied as a promising agent for this clinical use. The objective of the present study was to identify possible target organs of toxicity and propose a non-toxic dose of QX100626 for clinical usage. After single lethal dose oral and intravenous testing in rodents, some signs indicative of adverse CNS effects were observed. The minimum toxic dose of QX100626 for a single oral administration for dogs was 90.0mg/kgb.w., and the severe toxic dose was more than 300mg/kgb.w. The No Observed Adverse Effect Level (NOAEL) of QX100626 by daily oral administration for rats and dogs was 20mg/kg and 10mg/kg, respectively, whereas the minimum toxic dosages were 67 and 30mg/kg, respectively. All of the adverse effects suggested that kidney, digestive tract, as well as nervous, hematological, and respiratory systems might be the target organs of toxicity for humans induced by QX100626. The compound could be a safe alternative to other existing prokinetic agents for the treatment of functional bowel disorders.

Current and emerging pharmacotherapeutic options for irritable bowel syndrome

Treatment of irritable bowel syndrome (IBS) is challenging for both primary care physicians and gastroenterologists because of the heterogeneity of the patient population and the multifactorial pathophysiologies responsible for the symptoms in IBS. This review focuses on the current and emerging pharmacological treatments for IBS. Many of the current medications used to treat this disorder have distinct properties such as efficacy for different symptoms, safety profiles, contraindications, costs, dosing regimens, treatment duration and long-term data. All of these factors, in addition to patient preference and cognitive, food and environmental triggers, must be considered prior to any medication selection. This review will focus on randomized controlled trials with a general uniformity in study design, a rigorous patient selection and appropriate treatment durations. We will also discuss other exciting emerging treatments for IBS such as the µ-opioid receptor (agonists and antagonists), selective κ-opioid receptor agonists, anti-inflammatory drugs, serotonergic agents, bile acid modulators and intestinal bile acid transporters, which may prove promising in treating our patients.

The safety of novel drugs used to treat irritable bowel syndrome

INTRODUCTION

Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder with a high prevalence. Besides efficacy, the safety of each drugs used to treat GI disorders is an important issue in the drug development process.

AREAS COVERED

This article reviews all Phase I to IV clinical trials or case reports with results related to the safety of novel GI drugs. The drugs are currently approved or under evaluation for approval.

EXPERT OPINION

Most of the reported adverse events were related to the GI tract with mild-to-moderate severity. Diarrhea was significantly higher versus placebo following use of linaclotide and renzapride, similar to that of constipation with ramosetron. Lubiprostone, linaclotide and rifaximin with low systemic bioavailability have less adverse events and exert more advantageous results. Asimadoline acts peripherally on κ-opioid receptors and is not associated with CNS side effects. As lubiprostone and linaclotide cause dose-dependent adverse events, starting the treatment with the lowest effective doses is advised. Ramosetron is under evaluation for diarrhea-predominant IBS due to its acceptable safety and tolerability, besides its efficacy. Rifaximin, asimadoline and renzapride are still in need of more long-term studies regarding their safety.

Efficacy and tolerability of renzapride in irritable bowel syndrome: a meta-analysis of randomized, controlled clinical trials including 2528 patients

INTRODUCTION

By targeting different subtypes of 5-hydroxytryptamine (5HT) receptors in the gastrointestinal (GI) tract, several drugs have been introduced for the management of irritable bowel syndrome (IBS). Renzapride is a full agonist for 5HT4 receptor and an antagonist to 5HT2b and 5HT3 receptors which is thought a promising therapeutic agent for constipation predominant IBS (C-IBS) patients due to its accelerating effect on the GI tract. In this meta-analysis, our aim was to evaluate the efficacy and tolerability of renzapride in the management of IBS.

MATERIAL AND METHODS

A search was done from 1992 to February 2013 for placebo-controlled trials that investigated the efficacy of renzapride in IBS.

RESULTS

Relative risk (RR) for clinical efficacy in IBS patients treated for 5 weeks or less comparing renzapride to placebo was 1.07 (95% CI = 0.89-1.29, p = 0.38). This value for IBS patients treated for more than 5 weeks was 1.04 (95% CI = 0.78-1.239, p = 0.77). The RR for clinical efficacy in IBS patients treated with renzapride (4 mg) for 5 weeks or less and more than 5 weeks in comparison to placebo was 1.2 (95% CI = 0.97-1.48, p = 0.1) and 1.16 (95% CI = 0.98-1.37, p = 0.08), respectively, which were statistically non-significant but clinically important. The analysis of tolerability demonstrated that amongst different reported adverse effects, renzapride caused diarrhea more than placebo (RR = 1.61 with a 95% CI = 1.16-2.24, p = 0.004). The RR for withdrawals from renzapride compared to placebo was 1.58 (95% CI = 1.26-2.07, p = 0.0007).

CONCLUSIONS

Renzapride is not superior to placebo in relieving IBS symptoms and causes significant incidences of diarrhea and drop-outs due to adverse effects in treated patients vs. placebo. Thus, this medicine might be a cost burden to patients without providing good effectiveness.

On-demand treatment with alverine citrate/simeticone compared with standard treatments for irritable bowel syndrome: results of a randomised pragmatic study

BACKGROUND

In routine practice, irritable bowel syndrome (IBS) symptoms are often difficult to be relieved and impair significantly patients' quality of life (QoL). A randomised, double-blind, placebo-controlled study has shown the efficacy of alverine citrate/simeticone (ACS) combination for IBS symptom relief.

AIM

As IBS symptoms are often intermittent, this pragmatic study was designed to compare the efficacy of an on-demand ACS treatment vs. that of usual treatments.

METHODS

Rome III IBS patients were enrolled by 87 general practitioners who were randomly allocated to one of two therapeutic strategies: on-demand ACS or usual treatment chosen by the physician. The primary outcome measure was the improvement of the IBSQoL score between inclusion and month 6.

RESULTS

A total of 436 patients (mean age: 54.4 years; women: 73.4%) were included, 222 in the ACS arm and 214 patients in the usual treatment arm, which was mainly antispasmodics. At 6 months, improvement of IBSQoL was greater with ACS than with the usual treatment group (13.8 vs. 8.4; p < 0.0008). The IBS-severity symptom score (IBS-SSS) was lower with ACS than in the usual treatment arm with a mean (SE) decrease of 170.0 (6.6) vs. 110.7 (6.7), respectively (p = 0.0001). An IBS-SSS < 75 was more frequent in the ACS group (37.7% vs. 16.0%; p < 0.0001). Improvement of both abdominal pain and bloating severity was also greater with the on-demand ACS treatment, which was associated with both lower direct and indirect costs.

CONCLUSIONS

After 6 months, on-demand ACS treatment led to a greater improvement of QoL, reduced the burden of the disease and was more effective for IBS symptom relief than usual treatments.

Abdominal bloating: pathophysiology and treatment

Abdominal bloating is a very common and troublesome symptom of all ages, but it has not been fully understood to date. Bloating is usually associated with functional gastrointestinal disorders or organic diseases, but it may also appear alone. The pathophysiology of bloating remains ambiguous, although some evidences support the potential mechanisms, including gut hypersensitivity, impaired gas handling, altered gut microbiota, and abnormal abdominal-phrenic reflexes. Owing to the insufficient understanding of these mechanisms, the available therapeutic options are limited. However, medical treatment with some prokinetics, rifaximin, lubiprostone and linaclotide could be considered in the treatment of bloating. In addition, dietary intervention is important in relieving symptom in patients with bloating.

Colonic motility-promoting agents for treatment of chronic constipation

Chronic constipation (CC) is one of the most common functional gastroin testinal disorders. Possible etiologies for CC include alterations in gastrointestinal motility and secretion. Research efforts in CC have led to the identification of multifactorial and often overlapping etiologies including abnormalities in myenteric neurons, alterations in neurotransmitters and their receptors, and incoordination of the muscles of the pelvic floor or anorectum. In this article, we review the safety and efficacy of colonic motility-promoting agents, such as 5-HT modulators, motilin agonists, chloride-channel activators, opioid antagonists, uroguanylin and GC-2C receptor agonists, in the management of CC.

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.

Systematic review: cardiovascular safety profile of 5-HT(4) agonists developed for gastrointestinal disorders

BACKGROUND

The nonselective 5-HT(4) receptor agonists, cisapride and tegaserod have been associated with cardiovascular adverse events (AEs).

AIM

To perform a systematic review of the safety profile, particularly cardiovascular, of 5-HT(4) agonists developed for gastrointestinal disorders, and a nonsystematic summary of their pharmacology and clinical efficacy.

METHODS

Articles reporting data on cisapride, clebopride, prucalopride, mosapride, renzapride, tegaserod, TD-5108 (velusetrag) and ATI-7505 (naronapride) were identified through a systematic search of the Cochrane Library, Medline, Embase and Toxfile. Abstracts from UEGW 2006-2008 and DDW 2008-2010 were searched for these drug names, and pharmaceutical companies approached to provide unpublished data.

RESULTS

Retrieved articles on pharmacokinetics, human pharmacodynamics and clinical data with these 5-HT(4) agonists, are reviewed and summarised nonsystematically. Articles relating to cardiac safety and tolerability of these agents, including any relevant case reports, are reported systematically. Two nonselective 5-HT(4) agonists had reports of cardiovascular AEs: cisapride (QT prolongation) and tegaserod (ischaemia). Interactions with, respectively, the hERG cardiac potassium channel and 5-HT(1) receptor subtypes have been suggested to account for these effects. No cardiovascular safety concerns were reported for the newer, selective 5-HT(4) agonists prucalopride, velusetrag, naronapride, or for nonselective 5-HT(4) agonists with no hERG or 5-HT(1) affinity (renzapride, clebopride, mosapride).

CONCLUSIONS

5-HT(4) agonists for GI disorders differ in chemical structure and selectivity for 5-HT(4) receptors. Selectivity for 5-HT(4) over non-5-HT(4) receptors may influence the agent's safety and overall risk-benefit profile. Based on available evidence, highly selective 5-HT(4) agonists may offer improved safety to treat patients with impaired GI motility.

Mixed 5-HT3 antagonists/5-HT4 agonists for irritable bowel syndrome: a systematic review

AIM: To systematically review the evidence for the efficacy and safety of mixed 5-HT₃ antagonists/5-HT₄ agonists in the treatment of irritable bowel syndrome (IBS).

METHODS: According to the recommendations of the Cochrane Collaboration, a meta-analysis was conducted on 2 841 patients from eight eligible trials with respect to the usage of these drugs.

RESULTS: The unimprovement in IBS global symptoms [42.7% vs 46.9%, RR = 0.91, 95% CI (0.58, 1.43)], abdominal pain [53.2% vs 59.3%, RR = 0.90, 95% CI (0.72, 1.11)] or constipation [54.0% vs 58.5%, RR = 0.91, 95%CI (0.74, 1.12)] did not differ significantly in the presence of cisapride vs placebo. In the presence of renzapride, lower doses (1 mg/d and 2 mg/d) were found not to be superior to placebo in attenuating global symptoms [RR = 0.95, 95% CI (0.67, 1.35); RR = 0.79, 95% CI (0.67, 1.17)]; however, high dose of renzapride (4 mg/d) resulted in a significant difference [67.8 % vs 73.9%, RR = 0.91, 95% CI (0.86, 0.96)]. There was no significant difference in the incidence of adverse events among cisapride [RR = 1.52, 95% CI (0.58, 3.99)], renzapride [RR = 1.11, 95% CI (0.98, 1.24)] and placebo.

CONCLUSION: Except for high dose of renzapride (4 mg/d) which could relieve the global symptoms in IBS-C patients, there was no sufficient evidence to indicate that low dose renzapride or cisapride might be used to improve the global symptoms, abdominal pain as well as constipation discomfort.

Role of serotonin in the pathogenesis of chronic constipation

Serotonin (5-hydroxytryptamine, 5-HT) is a monoamine neurotransmitter of profound importance in the enteric nervous system. About 95% of the serotonin in the body is found in the GI tract; 90% is in enterochromaffin cells (EC cells) and the remaining 10% in enteric neurons. It plays a key role in the initiation of peristaltic and secretory reflexes and in the modulation of visceral sensations. There are many reports of serotonin in functional bowel disorders, and most of them mainly focus on irritable bowel syndrome (IBS), but serotonin in constipation is rarely reported. Chronic constipation (CC) is a commonly encountered disease, especially in elderly patients. The role of 5-HT plays in CC has been emphasized, and its effects in physiology, pathology and treatment of CC are continuously being resolved. This article is a review of the progress in understanding the role of 5-HT in the pathogenesis and treatment of chronic constipation.

[Guidelines for the treatment of irritable bowel syndrome]

Traditional symptom-based therapies of irritable bowel syndrome (IBS) are directed at the relief of individual IBS symptoms, but they are often of limited efficacy in addressing the entire symptom complex. Combinations of drugs to target bothersome symptoms are suggested as the first-line pharmacologic treatment. Increasing knowledge of the pathophysiology and molecular mechanisms of IBS has resulted in the development of several new therapeutic approaches. Thirteen consensus statements for the treatment of IBS were developed using the modified Delphi approach. Exclusion diets have modest efficacy in improving symptoms in some IBS patients. Symptom-based therapies with dietary fiber, bulking agents, laxatives, antispasmodics and laxatives are effective in the improvement of some individual symptoms, e.g. dietary fiber and bulking agents for constipation, laxatives for constipation, antispasmodics for abdominal pain and discomfort, antidiarrheals for diarrhea. 5HT3 receptor antagonists and 5HT((4)) receptor agonists are effective in the relief of global IBS symptoms and individual symptoms such as abdominal pain and abnormal bowel habits. A short term course of nonabsorbable antibiotics may improve global IBS symptoms, particularly in patients with diarrhea- predominant IBS. Some probiotics appear to have the potential benefit in improving global IBS symptoms. Selective C-2 chloride channel activator is more effective than placebo at relieving global IBS symptoms in patients with constipation-predominant IBS. Both tricyclic antidepressants and selective serotonin reuptake inhibitors are equally effective in relieving global IBS symptoms, and have some benefits in treating abdominal pain. Certain types of psychologic therapy may be effective in improving global symptoms in some IBS patients. Further studies are strongly needed to develop better treatment strategies for Korean patients with IBS.

[Guidelines for the treatment of constipation]

While constipation is a common symptom in Korea, there are no existing treatment guidelines. Although constipation may occur as a result of organic cause, there is no obstructive mucosal or structural cause in the vast majority of patients with constipation. The present paper deals with only the management of functional constipation: lifestyle changes; bulking agents and stool softeners; osmotic agents; stimulant laxatives; prokinetics; biofeedback and surgical treatments. Exercise and dietary fiber are helpful in some patients with constipation. Laxatives including bulking agents, stool softeners, osmotic agents, and stimulant laxatives have been found to be more effective than placebo at relieving symptoms of constipation. New enterokinetic agents that affect peristalsis through selective interaction with 5-hydroxytryptamine-4 receptors can be effective in patients with constipation who cannot get adequate relief from current laxatives. Biofeedback can relieve symptoms in selected patients with pelvic floor dyssynergia. Surgical treatments can be helpful in some patients with refractory constipation.

Treatment of irritable bowel syndrome in women

Irritable bowel syndrome (IBS) is a complex clinical process with multiple pathophysiologic mechanisms. There has recently been a shift in the treatment of patients with severe IBS symptoms to disease-modifying therapies as opposed to symptomatic treatment. Because pathophysiologic differences exist between men and women, so does the efficacy of treatment options. These differences could further explain gender-related differences in disease prevalence and treatment response. A brief discussion of the definition, epidemiology, and diagnostic criteria of IBS is followed by a comprehensive review of the current treatment choices and potential future therapeutic options of IBS in women.

Current management strategies and therapeutic targets in chronic constipation

Constipated patients who are refractory to simple lifestyle interventions will usually resort to laxatives, whether prescribed or over the counter. Clinical trial evidence is scarce for older medications such as laxatives, especially with a condition as chronic and subjective as constipation. Newer polyethylene glycol-based laxatives have been investigated under rigorous clinical trial settings, but comparisons between different laxatives are not available. Newer prokinetic agents, targeting peristalsis, intestinal secretion and the colonic flora, have been developed for laxative refractory constipation. This review focuses on the evidence for each of these agents, and the relative indications for each of them.

Investigational agents for the irritable bowel syndrome

IMPORTANCE OF THE FIELD

Irritable bowel syndrome (IBS) is a common disorder with significant health and economic consequences. The etiology of IBS is complex and appears to be multifactorial. Traditional IBS therapies have been directed primarily at the relief of individual symptoms but have been largely disappointing. This has triggered the search for newer treatment strategies with improved patient outcomes.

AREAS COVERED IN THIS REVIEW

Enhanced knowledge about the putative pathophysiology of IBS has allowed the identification of new mechanistic targets for treatment. Our aim is to review emerging and promising drugs in the treatment of IBS based on disease pathophysiology. Data were extracted using Medline and PubMed search engines until January 2010. Abstracts were identified through 'Web of Science' and abstract supplements of major gastrointestinal scientific meetings. Drugs were classified according to mechanism of action and those with efficacy in trials involving human subjects examined.

WHAT THE READER WILL GAIN

Additional insight into the pathophysiology as well as current and prospective treatments of IBS.

TAKE HOME MESSAGE

A multitude of putative drug targets have been identified and some novel treatments have progressed through to human clinical trials, but very few will be approved for the market in the near future. Moreover, and in keeping with the complex and multifactorial nature of this syndrome, it is unlikely that there will be one dominant and universally effective form of therapy for all IBS patients.

Diagnosis and treatment of irritable bowel syndrome: advances and challenges

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders and represents a major public health problem. The advances in understanding the pathophysiology and pathogenesis of IBS have revolutionized the treatment modality for the disease. Currently commonly used drugs for IBS include drugs acting on serotonin receptors or serotonin transporters, antidepressants, selective chloride channel activators, cholecystokinin antagonists, atypical benzodiazepines, antibiotics, probiotics and herbal medicine. In recent years, there has been public concern over several new drugs for IBS (i.e., alosetron and tegaserod) because of their association with ischemic colitis and cardiovascular disease. A series of systematic reviews and randomized controlled trials have been performed to evaluate the efficacy of different treatments for IBS.

Meta-analysis: factors affecting placebo response rate in the irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract with a significant placebo response.

AIM

To conduct a systematic review and meta-analysis examining the magnitude of placebo response rate in treatment trials for IBS.

METHODS

MEDLINE, EMBASE and the Cochrane central register of controlled trials were searched to identify randomized controlled trials (RCTs) comparing pharmacological therapies with placebo in adult IBS patients. Studies reported either global assessment of IBS symptom cure or improvement or abdominal pain cure or improvement. Data were extracted as intention-to-treat analyses with drop-outs assumed to be treatment failures and pooled using a random-effects model. Proportion of placebo patients experiencing symptom improvement or resolution was reported with a 95% confidence interval (CI). Effect of trial characteristics on magnitude of placebo response was examined.

RESULTS

In all, 73 RCTs were eligible, including 8364 patients with IBS allocated to placebo. Pooled placebo response rate across all RCTs was 37.5% (95% CI 34.4-40.6%). Rates were higher in European RCTs, RCTs that used physician-reported outcomes and RCTs using shorter duration of therapy.

CONCLUSIONS

Placebo response rates across RCTs of pharmacological therapies in IBS were high. Future research should identify patient characteristics predicting placebo response.

[New drugs for the treatment of constipation]

This review introduces new therapeutic options in the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation. Therefore, prucalopride and lubiprostone are discussed including their mechanisms and side effects. In addition, other substances that are currently under evaluation such as renzapride and linaclotide are described, since recent results showed a significant effect in patients with constipation. Thus, after the withdrawal of tegaserod due to cardiac side effects, new potent drugs are now available for the treatment of constipation.

Pharmacological management of constipation

The approach of this review is to give a pragmatic approach to using laxatives, based on a combination of what is known about mechanism of action and the available literature on evidence.

[Therapeutic targets]

Based on better recent knowledge of the factors involved in triggering visceral hyperalgesia, the therapeutic approach to irritable bowel syndrome (IBS) treatment is changing. The classical approach targeting first bowel movement alterations or motility disorders using spasmolytic agents has to be replaced by visceral antinociceptive drugs. Several mediators and receptors involved in gut hyperalgesia have already been identified. Serotonin (5-HT), tachykinins, CCK, NGF, and other mediators are involved in experimental models of gut hyperalgesia, and related receptor antagonists have already been introduced in clinical trials. However, IBS is associated with mucosal immune stimulation, considered a microinflammatory state associated with increased density of immunocytes and mast cells, offering new targets. Altered mucosal barrier permeability with increased entry of toxins and bacteria is considered to be responsible for the mucosal microinflammation. Endogenous but predominantly luminal factors have been identified as factors responsible for such altered permeability. These clinical data have opened the door to promising future drugs able to prevent or blunt such permeability alteration, which therefore may constitute a pathophysiological treatment for IBS.

Efficacy of 5-HT3 antagonists and 5-HT4 agonists in irritable bowel syndrome: systematic review and meta-analysis

OBJECTIVES

Irritable bowel syndrome (IBS) is a chronic functional disorder. 5-Hydroxytryptamine (5-HT) is a key modulator of gastrointestinal sensorimotor function. Many patients have IBS that can be difficult to treat, which has led to the development of newer agents, such as 5-HT(3) antagonists and 5-HT(4) agonists. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to estimate the efficacy of all available 5-HT agents in IBS.

METHODS

MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to June 2008). Trials recruiting adults with IBS in primary, secondary, or tertiary care comparing 5-HT(3) antagonists or 5-HT(4) agonists with placebo were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). The number needed to treat (NNT) was calculated from the reciprocal of the risk difference.

RESULTS

The strategic search identified 1,593 citations. A total of 29 RCTs were eligible for inclusion; placebo was compared with 5-HT(3) antagonists in 11 RCTs, with tegaserod in 11, and with mixed 5-HT(3) antagonists/5-HT(4) agonists in 7. The study quality was generally high. The RR of IBS symptoms persisting with 5-HT(3) antagonists vs. placebo was 0.78 (95% CI: 0.71-0.86), with a similar benefit for both alosetron and cilansetron. Tegaserod was also superior to placebo (RR=0.85; 95% CI: 0.80-0.90). Renzapride and cisapride had no benefit in IBS.

CONCLUSIONS

Alosetron, cilansetron, and tegaserod are all effective in the treatment of IBS. Serious adverse events were rare in the eligible RCTs included in this systematic review.

Therapeutic advances in functional gastrointestinal disease: irritable bowel syndrome

Reported prevalence rates of irritable bowel syndrome (IBS) are between 8% to 20% in the US general population with an average medical expenditure of US$1.35 billion direct and US$205 million indirect costs. Current pathophysiologic theories are based on abnormalities of both the brain and gut, thus setting a new stage for current and future therapeutic approaches. There are numerous treatment options in IBS acting centrally and peripherally by influencing motility and visceral sensitivity. Clinical evidence is variable; however, newer emerging treatments are being evaluated using better-designed clinical trials. Accurate assessment of IBS drug efficacy is still hampered by heterogeneity of the IBS population. Novel methods such as pharmacogenomics or brain imaging may be helpful in the future to better understand and characterize IBS patient subtypes, and this in turn will lead to more specific and efficient therapeutic options. Patient subpopulation measurement of side effects is also a clinical challenge and further understanding could improve treatment efficacy enhancing the patient compliance.