A randomized placebo-controlled trial on the effects of Menthacarin, a proprietary peppermint- and caraway-oil-preparation, on symptoms and quality of life in patients with functional dyspepsia

Menthacarin treatment attenuates nociception in models of visceral hypersensitivity

BACKGROUND

Chronic visceral hypersensitivity is closely associated with irritable bowel syndrome (IBS), a very common disorder which significantly impairs quality of life, characterized by abdominal pain, and distension. Imaging studies have found that IBS patients show higher metabolic activities and functional differences from normal controls in the anterior cingulate cortex (ACC), in response to visceral pain stimulation. Non-clinical data and clinical data suggest that medicinal products containing essential oils such as peppermint or caraway oil exert beneficial effects on IBS symptoms.

METHODS

We assessed acute and long-term treatment effects of a mixture of peppermint and caraway essential oils (Menthacarin) on brain electrophysiological markers of gut pain sensitivity in two rat models of visceral hypersensitivity.

KEY RESULTS

Chronic administration of corticosteroids and acute repeated mechanical hyperstimulation under anesthesia induced hyperalgesia and hypersensitivity, characterized by an increase in electrophysiological excitatory responses of ACC neurons to colorectal distension (CRD) and an increase in the proportion of neurons responding to otherwise subthreshold stimulation, respectively. Long-term, but not acute, oral administration of Menthacarin (60 mg kg-1 day-1) significantly reduced the net excitatory response to CRD in normally responsive control animals and counteracted the development of visceral hyperalgesia and hypersensitivity induced by repeated corticosterone administration and acute mechanical stimulation.

CONCLUSIONS & INFERENCES

The present study shows that, using the CRD method, chronic Menthacarin administration at a clinically relevant dose attenuates the neuronal discharge associated with visceral pain stimuli in the rat ACC, particularly in models of hypersensitivity, suggesting a potential for treating exaggerated visceral pain sensitivity.

Integrated traditional herbal medicine in the treatment of gastrointestinal disorder: the pattern of use and the knowledge of safety among the Eastern Region Saudi population

BACKGROUND

Herbal medicine is commonly integrated with conventional medicine in Saudi Arabia, especially for the management of digestive disorders. However, the majority of Saudis use herbal remedies without prior consultation with a physician, which raises concerns about their appropriate and safe use. The aim of this study was to assess the level of awareness among the Saudi population regarding the proper utilization and potential adverse effects of frequently used herbs for the treatment of gastrointestinal (GI) diseases.

METHODS

A cross-sectional survey was conducted in Saudi Arabia from January to March 2021. An electronic self-administered questionnaire was distributed.

RESULTS

A total of 543 participants from different age groups, educational levels, and cities across Saudi Arabia completed the study questionnaire. The most commonly used herbs at home by the participants were: myrrh, parsley, black seed, chamomile, mint, anise, clove, and green tea. 57.7% of the participants perceived herbs as safer than conventional medicines; 27.3% reported that using herbal remedies over conventional medicine was a family tradition, and 21.4% used herbs because they were cheaper than conventional medicines.

CONCLUSION

Herbal remedies, including myrrh, parsley, blackseed, chamomile, mint, and anise, are commonly employed for the treatment of gastrointestinal disorders in Saudi Arabia. However, the knowledge level of participants regarding potential side effects and drug-herb interactions was found to be deficient. As such, there is a pressing need for educational campaigns and community awareness programs to elucidate the proper usage of herbal remedies and to caution against their potential adverse effects.

Current state of research on the clinical benefits of herbal medicines for non-life-threatening ailments

Herbal medicines are becoming increasingly popular among patients because they are well tolerated and do not exert severe side effects. Nevertheless, they receive little consideration in therapeutic settings. The present article reviews the current state of research on the clinical benefits of herbal medicines on five indication groups, psychosomatic disorders, gynecological complaints, gastrointestinal disorders, urinary and upper respiratory tract infections. The study search was based on the database PubMed and concentrated on herbal medicines legally approved in Europe. After applying defined inclusion and exclusion criteria, 141 articles were selected: 59 for psychosomatic disorders (100% randomized controlled trials; RCTs), 20 for gynecological complaints (56% RCTs), 19 for gastrointestinal disorders (68% RCTs), 16 for urinary tract infections (UTI, 63% RCTs) and 24 for upper respiratory tract infections (URTI) (79% RCTs). For the majority of the studies, therapeutic benefits were evaluated by patient reported outcome measures (PROs). For psychosomatic disorders, gynecological complaints and URTI more than 80% of the study outcomes were positive, whereas the clinical benefit of herbal medicines for the treatment of UTI and gastrointestinal disorders was lower with 55%. The critical appraisal of the articles shows that there is a lack of high-quality studies and, with regard to gastrointestinal disorders, the clinical benefits of herbal medicines as a stand-alone form of therapy are unclear. According to the current state of knowledge, scientific evidence has still to be improved to allow integration of herbal medicines into guidelines and standard treatment regimens for the indications reviewed here. In addition to clinical data, real world data and outcome measures can add significant value to pave the way for herbal medicines into future therapeutic applications.

Non-Chinese herbal medicines for functional dyspepsia

BACKGROUND

One-third of people with gastrointestinal disorders, including functional dyspepsia, use some form of complementary and alternative medicine, including herbal medicines.

OBJECTIVES

The primary objective is to assess the effects of non-Chinese herbal medicines for the treatment of people with functional dyspepsia.

SEARCH METHODS

We searched the following electronic databases on 22 December 2022: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Allied and Complementary Medicine Database, Latin American and Caribbean Health Sciences Literature, among other sources, without placing language restrictions.

SELECTION CRITERIA

We included RCTs comparing non-Chinese herbal medicines versus placebo or other treatments in people with functional dyspepsia.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references, extracted data and assessed the risk of bias from trial reports. We used a random-effects model to calculate risk ratios (RRs) and mean differences (MDs). We created effect direction plots when meta-analysis was not possible, following the reporting guideline for Synthesis without Meta-analysis (SWiM). We used GRADE to assess the certainty of the evidence (CoE) for all outcomes.

MAIN RESULTS

We included 41 trials with 4477 participants that assessed 27 herbal medicines. This review evaluated global symptoms of functional dyspepsia, adverse events and quality of life; however, some studies did not report these outcomes. STW5 (Iberogast) may moderately improve global symptoms of dyspepsia compared with placebo at 28 to 56 days; however, the evidence is very uncertain (MD -2.64, 95% CI -4.39 to -0.90; I2 = 87%; 5 studies, 814 participants; very low CoE). STW5 may also increase the improvement rate compared to placebo at four to eight weeks' follow-up (RR 1.55, 95% CI 0.98 to 2.47; 2 studies, 324 participants; low CoE). There was little to no difference in adverse events for STW5 compared to placebo (RR 0.92, 95% CI 0.52 to 1.64; I2 = 0%; 4 studies, 786 participants; low CoE). STW5 may cause little to no difference in quality of life compared to placebo (no numerical data available, low CoE). Peppermint and caraway oil probably result in a large improvement in global symptoms of dyspepsia compared to placebo at four weeks (SMD -0.87, 95% CI -1.15 to -0.58; I2 = 0%; 2 studies, 210 participants; moderate CoE) and increase the improvement rate of global symptoms of dyspepsia (RR 1.53, 95% CI 1.30 to 1.81; I2 = 0%; 3 studies, 305 participants; moderate CoE). There may be little to no difference in the rate of adverse events between this intervention and placebo (RR 1.56, 95% CI 0.69 to 3.53; I2 = 47%; 3 studies, 305 participants; low CoE). The intervention probably improves the quality of life (measured on the Nepean Dyspepsia Index) (MD -131.40, 95% CI -193.76 to -69.04; 1 study, 99 participants; moderate CoE). Curcuma longa probably results in a moderate improvement global symptoms of dyspepsia compared to placebo at four weeks (MD -3.33, 95% CI -5.84 to -0.81; I2 = 50%; 2 studies, 110 participants; moderate CoE) and may increase the improvement rate (RR 1.50, 95% CI 1.06 to 2.11; 1 study, 76 participants; low CoE). There is probably little to no difference in the rate of adverse events between this intervention and placebo (RR 1.26, 95% CI 0.51 to 3.08; 1 study, 89 participants; moderate CoE). The intervention probably improves the quality of life, measured on the EQ-5D (MD 0.05, 95% CI 0.01 to 0.09; 1 study, 89 participants; moderate CoE). We found evidence that the following herbal medicines may improve symptoms of dyspepsia compared to placebo: Lafonesia pacari (RR 1.52, 95% CI 1.08 to 2.14; 1 study, 97 participants; moderate CoE), Nigella sativa (SMD -1.59, 95% CI -2.13 to -1.05; 1 study, 70 participants; high CoE), artichoke (SMD -0.34, 95% CI -0.59 to -0.09; 1 study, 244 participants; low CoE), Boensenbergia rotunda (SMD -2.22, 95% CI -2.62 to -1.83; 1 study, 160 participants; low CoE), Pistacia lenticus (SMD -0.33, 95% CI -0.66 to -0.01; 1 study, 148 participants; low CoE), Enteroplant (SMD -1.09, 95% CI -1.40 to -0.77; 1 study, 198 participants; low CoE), Ferula asafoetida (SMD -1.51, 95% CI -2.20 to -0.83; 1 study, 43 participants; low CoE), ginger and artichoke (RR 1.64, 95% CI 1.27 to 2.13; 1 study, 126 participants; low CoE), Glycyrrhiza glaba (SMD -1.86, 95% CI -2.54 to -1.19; 1 study, 50 participants; moderate CoE), OLNP-06 (RR 3.80, 95% CI 1.70 to 8.51; 1 study, 48 participants; low CoE), red pepper (SMD -1.07, 95% CI -1.89 to -0.26; 1 study, 27 participants; low CoE), Cuadrania tricuspidata (SMD -1.19, 95% CI -1.66 to -0.72; 1 study, 83 participants; low CoE), jollab (SMD -1.22, 95% CI -1.59 to -0.85; 1 study, 133 participants; low CoE), Pimpinella anisum (SMD -2.30, 95% CI -2.79 to -1.80; 1 study, 107 participants; low CoE). The following may provide little to no difference compared to placebo: Mentha pulegium (SMD -0.38, 95% CI -0.78 to 0.02; 1 study, 100 participants; moderate CoE) and cinnamon oil (SMD 0.38, 95% CI -0.17 to 0.94; 1 study, 51 participants; low CoE); moreover, Mentha longifolia may increase dyspeptic symptoms (SMD 0.46, 95% CI 0.04 to 0.88; 1 study, 88 participants; low CoE). Almost all the studies reported little to no difference in the rate of adverse events compared to placebo except for red pepper, which may result in a higher risk of adverse events compared to placebo (RR 4.31, 95% CI 1.56 to 11.89; 1 study, 27 participants; low CoE). With respect to the quality of life, most studies did not report this outcome. When compared to other interventions, essential oils may improve global symptoms of dyspepsia compared to omeprazole. Peppermint oil/caraway oil, STW5, Nigella sativa and Curcuma longa may provide little to no benefit compared to other treatments.

AUTHORS' CONCLUSIONS

Based on moderate to very low-certainty evidence, we identified some herbal medicines that may be effective in improving symptoms of dyspepsia. Moreover, these interventions may not be associated with important adverse events. More high-quality trials are needed on herbal medicines, especially including participants with common gastrointestinal comorbidities.

[Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice]

Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice Abstract: Functional dyspepsia (FD) and irritable bowel syndrome (IBS), two common gastrointestinal entities with overlapping symptoms, should be diagnosed according to Rome IV criteria. This includes one or more of the following symptoms: in FD, postprandial fullness, early satiation, epigastric pain or burning; in IBS, recurrent abdominal pain associated with defecation, change in frequency of stool or form of stool. To exclude structural diseases, attention should be paid to alarm symptoms. As far as treatment is concerned, a stepwise scheme proves to be effective for both diseases. Step 1: doctor-patient discussion with explanation of diagnosis and prognosis as well as clarification of therapy goals; lifestyle adaptations; use of phytotherapeutics; step 2: symptom-oriented medication: for FD, PPIs or prokinetics; for IBS, antispasmodics, secretagogues, laxatives, bile acid sequestrants, antidiarrheals, antibiotics, probiotics; step 3: visceral analgesics (antidepressants).

Gastroparesis syndromes: emerging drug targets and potential therapeutic opportunities

INTRODUCTION

Gastroparesis (Gp) and related disorders such as chronic unexplained nausea and vomiting and functional dyspepsia, known as gastropareis syndromes (GpS), have large unmet needs. Mainstays of GpS treatments are diet and drugs.

AREAS COVERED

The purpose of this review is to explore potential new medications and other therapies for gastroparesis. Before discussing possible new drugs, the currently used drugs are discussed. These include dopamine receptor antagonists, 5-hydroxytryptamine receptor agonists and antagonists, neurokinin-1 receptor antagonists and other anti-emetics. The article also considers future drugs that may be used for Gp, based on currently known pathophysiology.

EXPERT OPINION

Gaps in knowledge about the pathophysiology of gastroparesis and related syndromes are critical to developing therapeutic agents that will be successful. Recent major developments in the gastroparesis arena are related to microscopic anatomy, cellular function, and pathophysiology. The major challenges moving forward will be to develop the genetic and biochemical correlates of these major developments in gastroparesis research.

Menthacarin for long-term treatment of functional dyspepsia - Results from a clinical trial follow-up

BACKGROUND

Menthacarin was shown to be effective and safe in clinical trials in patients with functional dyspepsia (FD). Long-term treatment results have not been reported yet.

METHODS

An open-label, 11-month follow-up (FU) was offered to FD patients who had undergone treatment with Menthacarin (1 gastro-resistant capsule b.i.d. vs. placebo (PL)) in a 4-week, double-blind, clinical trial. During FU, all patients (former verum and PL) were treated with 1 gastro-resistant capsule Menthacarin b.i.d. Main outcomes were the changes in pain intensity and severity of sensation of pressure, heaviness, and fullness from original baseline and global improvement.

RESULTS

70 patients were included in the analyses (former Menthacarin group: 36, former PL group: 34). At the end of the PL-controlled study phase, all 3 main efficacy variables were statistically significantly improved in the Menthacarin group compared to PL. In the FU phase, former PL patients started to improve under Menthacarin treatment towards the outcomes seen in the former Menthacarin group (alignment at approximately 6 months), while former Menthacarin patients showed sustained or even continuously improved outcomes by month 12. At study end, more than 90% of patients were "much or very much improved" in both groups. Menthacarin treatment was well tolerated.

CONCLUSIONS

The favorable effects seen in the FU period suggest that Menthacarin is a valuable treatment option in FD patients who require symptomatic treatment also in the longer term for up to 12 months.

The treatment of functional dyspepsia: present and future

INTRODUCTION

Functional dyspepsia (FD) is a prevalent, but frequently overlooked and/or under diagnosed disorder of gut-brain interaction (DGBI). Functional dyspepsia frequently co-exists with other DGBIs, and persistent symptoms have a significant impact on patients' quality of life. A variety of therapies (e.g. diet, probiotics, antibiotics, acid suppressants, neuromodulators, prokinetics) are employed to treat the multiple symptoms of FD, although none are uniformly effective.

AREAS COVERED

This review covers currently available therapies for the treatment of FD in addition to novel and emerging therapies that may change the treatment paradigm in the near future. PubMed, Embase and the Cochrane data bank were searched from 1990 to October 2022 for relevant articles.

EXPERT OPINION

Dietary intervention, eradication of H. pylori, and/or a trial of acid suppression are reasonable initial treatment options for patients with FD. Neuromodulators and fundic accommodation agents are underemployed and should be used more routinely by healthcare providers, especially for patients with moderate-severe symptoms. Alternative therapies, such as cognitive behavioral therapy and hypnotherapy, are gaining recognition as safe and effective treatments for FD and can be used alone or in combination with medications. Virtual reality has the potential to significantly improve global FD symptoms.

A novel duodenal-release formulation of caraway oil and L-menthol is a safe, effective and well tolerated therapy for functional dyspepsia

BACKGROUND

A randomized, placebo-controlled clinical trial (FDREST) of a novel formulation of caraway oil and L-menthol (COLM-SST) demonstrated symptom relief in patients with functional dyspepsia (FD). Two follow-up studies were conducted to evaluate patient satisfaction, self-regulated dosing, and long-term safety data: FDACT, Functional Dyspepsia Adherence and Compliance Trial, and FDSU36, Functional Dyspepsia Safety Update at 36 months.

METHODS

A patient reported outcomes (PRO) questionnaire was designed and distributed online to assess real-world satisfaction and dosing frequency of open-label COLM-SST in patients with FD. A separate study analyzing voluntary safety surveillance data evaluated the frequency and severity of reported adverse events (AEs).

RESULTS

A total of 600 FD patients were enrolled in the PRO study. Ninety five percent of respondents reported a major or moderate improvement in their FD symptoms and 91.7% indicated a major or moderate improvement in quality of life (QOL) using COLM-SST. Between 1 and 4 capsules were consumed daily by 91.2% of respondents, with 56.2% taking them before meals. Symptom relief was rapid, with 86.4% of respondents indicating relief within 2 h of taking COLM-SST. Few adverse events (AEs) were reported (0.0187%) by patients using COLM-SST. No serious AEs were identified.

CONCLUSION

COLM-SST is safe, well tolerated, and provides rapid relief of FD symptoms. These findings, demonstrated in the FDREST trial, were further supported by a large prospective PRO study evaluating self-regulated dosing frequency, symptom improvement, and QOL. COLM-SST was well-tolerated based on review of AE data at 36 months.

[Irritable bowel syndrome and functional dyspepsia : Diagnosis and treatment]

Irritable bowel syndrome (IBS) and functional dyspepsia are chronic diseases of the digestive tract that challenge both patients and physicians due to their difficult diagnosis and limited treatment options. The international Rome IV diagnostic criteria are commonly used for research purposes. For IBS, the diagnostic criteria based on the German S3 guideline offer a less complicated alternative for everyday clinical practice. A thorough history and basic diagnostic work-up are essential for diagnosis, as reliable biomarkers are still lacking. Clinical manifestations of both disorders are variable, and it has been useful to allocate subtypes based on leading symptom clusters; these may facilitate the choice of diagnostic tests as well as symptomatic treatment approaches. Used correctly, the combination of available drug (mostly off-label) and non-drug options can help to reduce symptoms and improve quality of life.

Testing the Arabic-Saudi Arabia version of the Rome IV Diagnostic Questionnaire for functional gastrointestinal disorders for Children living in Saudi Arabia

Functional gastrointestinal disorders (FGID) are a worldwide phenomenon described by painful, recurrent or chronic gastrointestinal (GI) symptoms. Variable types of FGID exist in a significant portion of children in Saudi Arabia (SA). While the studies and reports on child FGID are limited, the available ones show a notable significance of FGID in children in SA. The self-report Rome IV Diagnostic Questionnaire (DQ) globally recognizes the selection of symptom criteria and incidence thresholds. Using such a questionnaire would help clinicians provide a provisional diagnosis, serve as a case definition for epidemiological surveys, and identify inclusion criteria for clinical trials. This research aimed to pilot test the collective FGIDs prevalence among preschool children in Jeddah city and its countryside of Saudi Arabia, using Rome IV DQ in Arabic-SA. Of the 59 responses, 11.8% (n = 7), 5% (n = 3), 1 (1.6%), and 1 (1.6%) participants have functional dyspepsia, functional constipation, functional irritable bowel syndrome, and functional aerophagia, respectively according to the Rome IV criteria. The tested translated DQ in this study was the first translated version available in Arabic- SA, which could provide researchers and clinicians in SA with a diagnostic tool for FGIDs. However, because this study is a pilot study in a new field, the conclusions cannot be extrapolated to the demographic of the targeted population of children. The same researchers plan a larger study to use the current results and a larger calculated sample to assess FGIDs prevalence in children 4+ years old in Jeddah and its countryside, Saudi Arabia.

Combined Curcumin and Lansoprazole-Loaded Bioactive Solid Self-Nanoemulsifying Drug Delivery Systems (Bio-SSNEDDS)

BACKGROUND

The current study aimed to design a novel combination of lansoprazole (LNS) and curcumin (CUR) solid oral dosage form using bioactive self-nanoemulsifying drug delivery systems (Bio-SSNEDDS).

METHODS

Liquid SNEDDS were prepared using the lipid-excipients: Imwitor988 (cosurfactant), Kolliphor El (surfactant), the bioactive black seed (BSO) and/or zanthoxylum rhetsa seed oils (ZRO). Liquid SNEDDS were loaded with CUR and LNS, then solidified using commercially available (uncured) and processed (cured) Neusilin^® US2 (NUS2) adsorbent. A novel UHPLC method was validated to simultaneously quantify CUR and LNS in lipid-based formulations. The liquid SNEDDS were characterized in terms of self-emulsification, droplet size and zeta-potential measurements. The solidified SNEDDS were characterized by differential scanning calorimetry (DSC), X-ray powder diffraction (XRD), scanning electron microscopy (SEM), in vitro dissolution and stability in accelerated storage conditions.

RESULTS

Liquid SNEDDS containing BSO produced a transparent appearance and ultra-fine droplet size (14 nm) upon aqueous dilution. The solidified SNEDDS using cured and uncured NUS2 showed complete solidification with no particle agglomeration. DSC and XRD confirmed the conversion of crystalline CUR and LNS to the amorphous form in all solid SNEDDS samples. SEM images showed that CUR/LNS-SNEDDS were relatively spherical and regular in shape. The optimized solid SNEDDS showed higher percent of cumulative release as compared to the pure drugs. Curing NUS2 with 10% PVP led to significant enhancement of CUR and LNS dissolution efficiencies (up to 1.82- and 2.75-fold, respectively) compared to uncured NUS2-based solid SNEDDS. These findings could be attributed to the significant (50%) reduction in the micropore area% in cured NUS2 which reflects blocking very small pores allowing more space for the self-emulsification process to take place in the larger-size pores. Solid SNEDDS showed significant enhancement of liquid SNEDDS stability after 6 months storage in accelerated conditions.

CONCLUSIONS

The developed Bio-SSNEDDS of CUR and LNS using processed NUS2 could be used as a potential combination therapy to improve the treatment of peptic ulcers.

Efficacy of herbal treatments for functional dyspepsia: A systematic review and meta-analysis of randomized clinical trials

Functional dyspepsia (FD) is a very common condition globally. Relevant keywords were searched for in title and abstract of selected databases, that is, Medline/PubMed, Scopus, Embase, Web of knowledge, and Google Scholar. Placebo and active-control trials on herbal remedies amongst adults who were diagnosed with FD were included. Dichotomous outcomes were presented as relative risk (RR) with 95% confidence interval (CI) and continuous outcomes were presented as pooled standardized mean difference (SMD) with 95% CI. Forty-nine randomized controlled trials (RCTs) were entered into meta-analysis (6,987 subjects). Herbal remedies resulted in a higher improvement in FD symptoms in comparison with the placebo (SMD = -0.58 [-0.66- -0.51], p < .00001 and RR = 1.73 [1.62-1.85], p < .00001). No significant difference between herbal remedies and placebo in the incidence of adverse events was observed (12.27 vs. 8.41%, RR = 1.06 [0.91-1.23], p = .45). Also, herbal remedies resulted in a higher improvement in quality of life in comparison with placebo (SMD = -0.64 [-0.73- -0.55], p < .00001). When comparing herbal remedies with conventional medicine through sensitivity analysis, no outcomes were significantly different (p > .05). Herbal remedies might be efficacious and safe in treating FD, and demonstrate comparable effect sizes for efficacy to conventional treatments. Further high-quality studies are warranted to firmly establish the clinical efficacy of the herbal remedies.

Role of Neuromodulators for the Management of Post-Gastric-Fundoplication Dyspepsia: A Retrospective Series

Post-fundoplication dyspepsia is a common complication of gastric fundoplication surgeries. This can be attributable to the loss of fundal relaxation, decreased gastric accommodation, and/or alterations in gastric motility and sensitivity following fundoplication. The role of neuromodulators in the management of such symptoms is unknown. We retrospectively assessed the efficacy of neuromodulators such as tricyclic antidepressants, buspirone, and mirtazapine for the management of post-fundoplication dyspepsia.

Meta-Analysis: Placebo Response and Its Determinants in Functional Dyspepsia

INTRODUCTION

Placebo response rates are relatively higher in clinical trials of disorders of brain-gut interaction. However, placebo response in functional dyspepsia (FD) has not been well described. Minimizing placebo response is important in drug development. We therefore conducted a meta-analysis to determine placebo response in trials for FD and to identify factors affecting placebo response rates.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify double-blinded randomized controlled trials (RCTs) comparing medication with placebo in patients with FD. Both symptom improvement and complete relief were considered as separate primary endpoints in the analysis. Proportions of placebo patients experiencing any symptom improvement or complete relief were calculated. Dropouts after randomization for any reason were assumed to represent treatment failure for data extraction and analysis. Placebo response was pooled by a random-effects model, and effects of trial characteristics on the magnitude of placebo response were evaluated.

RESULTS

In 58 eligible placebo-controlled RCTs of FD from 52 selected citations, 6,732 of 17,890 participants in all trials received placebo. Pooled placebo response rates for symptom improvement and complete relief were 44.3% and 15.6%, respectively. The placebo response rate was lower when improvements were assessed for ≥8 weeks. Trials assessing complete symptom relief showed lower placebo response rates even in trials for <8 weeks.

DISCUSSION

Our systematic review and meta-analysis showed that pooled placebo response rates in double-blinded RCTs of FD depended on efficacy criteria. Trials assessing complete symptom relief showed stable low placebo response rates in short-term trials.

L-Menthol for Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis

In randomized controlled trials, L-menthol inhibits gastrointestinal peristalsis during endoscopy. Our goal was to quantitatively synthesize the available evidence to evaluate the efficacy and safety of L-menthol for gastrointestinal endoscopy.

Persian Herbal Medicine in Functional Dyspepsia: A Systematic Review

INTRODUCTION

According to Rome IV, functional dyspepsia is diagnosed with the presence of dyspepsia in the absence of organic or metabolic causes. FD caused by several factors, such as impaired gastric accommodation and hypersensitivity to gastric distention. Several studies have reported the effectiveness of herbal medicine on FD. This article, thus, reviews Persian herbal medicine in FD.

METHODS

Electronic databases, including Pubmed, Scopus, Cochrane, Embase, Web of science and Ovid, were searched so as to find clinical articles related to dyspepsia and herbal medicine by July 2019. Our search strategies were traditional medicine, complementary and alternative medicine, herb, plant, and dyspepsia. We excluded all articles except Persian clinical trials.

RESULTS

We found 34 clinical trials with 15 herbs and 4 compound herbal remedies like Asparagus racemosus, Brassica oleracea, Cynara scolymus, Ocimum basilicum, Mentha longifolia, Mentha pulegium, Mentha piperata, Pimpinella anisum, Nigella sativa, Mastic gum, Curcuma longa, Pistatio Atlantica, Glycyrrhiza glabra, Solanum tuberosum and Zingiber officinale and compound remedies of Rosa damascene & Crocus sativus, Trachyspermum copticom & Apium graveolence, Carum carvi & Mentha pipperata, Gingiber officinalis & Cynara scolymus are effective in functional dyspepsia.

CONCLUSION

Many people use herbal and traditional remedies for the treatment of disorders such as gastrointestinal disorders, especially in Asian countries. Several studies reported the efficacy of herbal medicine in functional dyspepsia. Although their mechanisms are not fully understood, it seems they can modulate GI motility and improve symptoms of FD.

Herbal medicines in functional dyspepsia-Untapped opportunities not without risks

BACKGROUND

Contemporary treatments for functional dyspepsia have limitations. Herbal medicine has been suggested as adjunctive treatment. With growing scientific recognition and public interests, an in-depth review of this is timely.

AIMS/PURPOSE

To evaluate the therapeutic potential and problems that may be associated with the adoption of herbal medicines in functional dyspepsia.

METHODS

We reviewed the treatment landscape of functional dyspepsia and assessed the scientific community's interest in herbal medicine. Preclinical pharmacological and clinical trial data were reviewed for several herbal medicines available in the market. Challenges associated with adoption of herbal medicine in mainstream medicine were critically evaluated.

RESULTS

We found that herbal medicines frequently comprise a combination of herbs with multiple reported pharmacological effects on gastrointestinal motility and secretory functions, as well as cytoprotective and psychotropic properties. We identified a number of commercially available herbal products that have undergone rigorous clinical trials, involving large numbers of well-defined subjects, reporting both efficacy and safety for functional dyspepsia. Persisting concerns include lack of rigorous assessments for majority of products, toxicity, consistency of ingredients, dose standardizations, and quality control. We provide a quality framework for its evaluation.

CONCLUSIONS

We commend herbal medicine as a viable future option in managing functional dyspepsia. An attractive appeal of herbal medicine is the prospect to simultaneously target multiple pathophysiological mechanisms. Wider adoption and acceptance of herbal medicines in treatment algorithms of functional dyspepsia will require the application of the scientific rigor expected of chemical therapies, to all stages of their development and evaluation.

Menthacarin induces calcium ion influx in sensory neurons, macrophages and colonic organoids of mice

AIMS

Menthacarin is a herbal combination that is clinically used for the treatment of functional gastrointestinal disorders (FGIDs). In several clinical studies, Menthacarin reduced visceral hypersensitivity-related symptoms. Pathogenesis of visceral hypersensitivity is multifactorial. This involves several cell types and different transient receptor potential ion channels (TRPs); these ion channels are highly conductive for calcium ions. Since transient changes in cytosolic calcium levels are crucial for many functions of living cells, we investigated if Menthacarin can induce calcium influx in sensory, largely nociceptive, neurons from dorsal root ganglia (DRG), peritoneal macrophages (PMs) and colonic organoids.

MAIN METHODS

We employed the calcium imaging technique on sensory neurons from DRG, PMs and colonic organoids isolated from mice. All cells were superfused by Menthacarin at several concentrations (600, 1200, 1800 μg/ml) during the experiments, followed by calcium ionophor ionomycin (Iono., 1 μM) as a positive control.

KEY FINDINGS

Menthacarin induced concentration-dependent calcium ion influx in all investigated cell types. Furthermore, repeated applications of Menthacarin induced tachyphylaxis (desensitisation) of calcium responses in sensory neurons and colonic organoids.

SIGNIFICANCE

Menthacarin-induced calcium influx into sensory neurons, macrophages and colonic organoids is probably related to its clinical desensitising effects in patients with FGIDs.

A Novel, Duodenal-Release Formulation of a Combination of Caraway Oil and L-Menthol for the Treatment of Functional Dyspepsia: A Randomized Controlled Trial

We conducted a randomized, placebo-controlled trial, which evaluated a novel formulation of caraway oil and L-menthol using microsphere-based site-specific targeting (COLM-SST) vs placebo in patients with functional dyspepsia (FD).

Herbal medicine in the treatment of functional gastrointestinal disorders: A systematic review with meta-analysis

BACKGROUND AND AIMS

The efficacy of herbal medicines (HMs) for functional gastrointestinal disorders (FGIDs) including irritable bowel syndrome (IBS), functional dyspepsia (FD) and functional constipation (FC) is controversial. A systematic review with meta-analysis was conducted to determine their effectiveness for FGIDs.

METHODS

We searched the following electronic databases till July 2019 with English language restriction: The Cochrane Library, EMBASE and PUBMED. Randomized double-blind controlled trials of HMs compared with placebo or conventional pharmacological drugs for adult FGIDs patients were included.

RESULTS

In total, 49 trials involving 7396 participants with FGIDs were included. The risk of bias was low in 9, unclear in 36, and high in 4 trials. More than 33 different herbal formulae were tested. HMs demonstrated statistically significant benefits for symptom improvement compared with placebo in 46 trials (RR = 1.67, 95% CI 1.48-1.88). When compared with conventional pharmacological therapy in 5 trials, HMs were found to be non-inferior (RR = 1.10, 95% CI 1.03-1.18). The number of trials with regards to FD, IBS and FC were 19, 23 and 7 respectively. Subgroup analysis found that HMs were better than placebo in alleviating symptoms for FD (RR = 1.50, 95% CI 1.32-1.69), IBS (RR = 1.62, 95% CI 1.32-1.97) and FC (RR = 3.83, 95% CI 2.26-6.50). HMs tended to have more patients with adverse events than placebo, but similar to conventional pharmacological drugs.

CONCLUSIONS

Our findings provide a positive signal for HMs as a potentially well-tolerated and effective treatment for FGIDs, deserving further examination in high-quality trials.

Current and emerging therapeutic options for the management of functional dyspepsia

Introduction: Functional Dyspepsia (FD), defined as chronic symptoms originating from the gastroduodenal region in absence of readily identifiable organic disease, is one of the most common gastrointestinal disorders. FD is divided into two subgroups: Post-Prandial Distress Syndrome (PDS) or meal-related FD, characterized by postprandial fullness and early satiation, and Epigastric Pain Syndrome (EPS) or meal-unrelated FD, characterized by epigastric pain and burning.Areas covered: This review summarizes the existing and off-label therapeutic options for FD.Expert opinion: The identification of mechanisms, the Rome IV classification, the reduction of PDS/EPS overlap and pictograms for symptom identification allow a better diagnosis and a more targeted treatment choice. Acotiamide, a first-in-class prokinetic agent available only in Japan and India, is the only agent of proven efficacy for FD, but clinicians use acid-suppressive therapy, prokinetics, neuromodulators and herbal therapies for treating FD symptoms. New emerging targets are duodenal low-grade inflammation with eosinophils and duodenal or other modified luminal microbiota.

Herbal Therapies in Functional Gastrointestinal Disorders: A Narrative Review and Clinical Implication

The pathophysiology of functional gastrointestinal disorders (FGIDs) is still unclear and various complex mechanisms have been suggested to be involved. In many cases, improvement of symptoms and quality of life (QoL) in patients with FGIDs is difficult to achieve with the single-targeted treatments alone and clinical application of these treatments can be challenging owing to the side effects. Herbal preparations as complementary and alternative medicine can control multiple treatment targets of FGIDs simultaneously and relatively safely. To date, many herbal ingredients and combination preparations have been proposed across different countries and together with a variety of traditional medicine. Among the herbal therapies that are comparatively considered to have an evidence base are iberogast (STW-5) and peppermint oil, which have been mainly studied and used in Europe, and rikkunshito and motilitone (DA-9701), which are extracted from natural substances in traditional medicine, are the focus of this review. These herbal medications have multi-target pharmacology similar to the etiology of FGIDs, such as altered intestinal sensory and motor function, inflammation, neurohormonal abnormality, and have displayed comparable efficacy and safety in controlled trials. To achieve the treatment goal of refractory FGIDs, extensive and high quality studies on the pharmacological mechanisms and clinical effects of these herbal medications as well as efforts to develop new promising herbal compounds are required.

A Combination of Peppermint Oil and Caraway Oil for the Treatment of Functional Dyspepsia: A Systematic Review and Meta-Analysis

A combination of peppermint oil and caraway oil (POCO) with its unique properties has been shown clinical benefits for FD. However, the potent statistical data to confirm its effects are lacking. This meta-analysis thus aimed at evaluating the efficacy and safety of POCO compared with placebo in treating patients with FD. We searched CENTRAL, PubMed, EMBASE (Ovid), Web of Science, Google Scholar, China National Knowledge Infrastructure database, Wanfang, and VIP databases for randomized clinical trials (RCTs) up to June 2019. Dichotomous data were shown as a risk ratio (RR) with 95% confidence intervals (CIs). All data were analyzed by Review Manager 5.2 software. The search identified 382 citations, and 5 RCTs (578 participants) were included. POCO showed a statistically significant effect in global improvement of FD symptoms (RR for not much or very much improvement 0.59, 95% CI: 0.49 to 0.71, P < 0.00001, I² 36%, NNT 3) and improvement in epigastric pain (RR 1.61, 95% CI: 1.28 to 2.03, P < 0.0001, I² 0%, NNT 3). There were no significant differences in the total number of adverse events between POCO and placebo (NNH 40). In conclusion, this is the first meta-analysis to assess the effects of POCO in FD. POCO is an effective and safe short-term treatment for FD. However, current findings are based on smaller sample sizes and low/very low quality of the evidence. More well-designed RCTs with large sample sizes of FD patients are required.

Review article: treatment options for functional dyspepsia

BACKGROUND

Functional dyspepsia, consisting of epigastric pain syndrome and postprandial distress syndrome, is a prevalent functional gastrointestinal disorder. To date, only limited treatment options are available and conflicting results in terms of efficacy have been reported. Consequently, nonpharmacological treatment options are increasingly being explored for functional dyspepsia.

AIM

To provide an overview of current pharmacological and nonpharmacological treatment options for functional dyspepsia.

METHODS

A literature search was conducted on Pubmed and other sources to identify relevant studies.

RESULTS

Acid suppressive therapy reduced symptoms in 30%-70% of the patients, with higher benefit in epigastric pain syndrome and superior effectiveness for proton pump inhibitors compared to H₂ -antagonists. Prokinetic agents, primarily used to treat postprandial distress syndrome, showed variable efficiency: 59%-81% responder rate for dopamine receptor antagonists, 32%-91% for serotonin-4-receptor agonists and 31%-80% for muscarinic receptor antagonists. H Pylori eradication, recommended in infected patients, was effective in 24%-82%. Refractory symptoms are addressed with neuromodulators. However, their efficacy in functional dyspepsia remains incompletely elucidated, available data showing symptom reduction in 27%-71% of the patients. Regarding herbal agents, peppermint oil reduced symptoms in 66%-91%, rikkunshito in 29%-34% and iberogast in 20%-95%. Lastly, acupuncture, cognitive behavioural therapy and hypnotherapy may help to provide symptom control, but research on their efficacy remains sparse.

CONCLUSIONS

None of the available therapies is effective in the majority of patients without being associated with major side effects. Developing new treatment options is challenging due to the heterogeneity of functional dyspepsia, the lack of readily identified target mechanisms and the poor association between pathophysiological disturbances and symptoms.

Caraway as Important Medicinal Plants in Management of Diseases

Carum carvi or caraway is traditionally used for treatment of indigestion, pneumonia, and as appetizer, galactagogue, and carminative. Essential oil, fixed oil and many other valuable extractive compounds with industrial applications are prepared from caraway. This review article has new deep research on caraway as medicinal plant. For preparing the manuscript, the information was extracted from accessible international databases (Google scholar, PubMed, Science direct, Springer, and Wiley), electronic resources and traditional books by key word of caraway or Carum carvi. The results of traditional studies exhibited that the galactagogue and carminative effects of caraway fruits are superior to other effects. Although, the traditional scholars used it as appetizer, while caraway was the main ingredient of anti-obesity drugs in traditional medicine, which has been confirmed in two modern clinical trials of human studies. Caraway oil in combination with peppermint oil or menthol is used for treatment of functional dyspepsia in clinical studies. Caraway oil topically on abdomen relieves the IBS symptoms in patient. Although, the use of caraway oil is not recommended in adults under 18 years due to insufficient data, but it can topically use as anti-colic and carminative agent in children or infants. The anti-aflatoxigenic, antioxidant and antimicrobial effects of caraway oil along with its reputation as spice help the industries to use it as natural preservatives and antioxidant agents.

Herbs and Spices in the Treatment of Functional Gastrointestinal Disorders: A Review of Clinical Trials

More than fifty percent of all new patient visits to pediatric gastroenterology clinics consult for functional abdominal pain disorders (FAPDs). In 2005, a technical report of the American Academy of Pediatrics and the North American Pediatric Gastroenterology, Hepatology and Nutrition society (NASPGHAN) found limited or inconclusive evidence for most therapeutic interventions for this group of disorders. The report did not include studies on herbs and spices. Since then, there has been an increasing interest in the use of complementary and alternative medicine (CAM) for the treatment of chronic pain disorders in children. About 40% of parents of pediatric gastroenterology patients have utilized CAM. This review evaluated the published literature on the effectiveness of CAM, specifically the use of herbs and spices, for the treatment of FAPDs. We found little evidence for most of the commonly used herbs and spices. Despite its common use, research on the efficacy, safety, and optimal dosage remains limited. There is evidence to suggest the benefit of peppermint oil and STW 5 for the treatment of FAPDs in children. The paucity of data on most therapies underscores the need for large clinical trials to assess their efficacy.

Reversal of visceral hypersensitivity in rat by Menthacarin® , a proprietary combination of essential oils from peppermint and caraway, coincides with mycobiome modulation

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder associated with altered gastrointestinal microflora and increased nociception to colonic distension. This visceral hypersensitivity can be reversed in our rat maternal separation model by fungicides. Menthacarin^® is a proprietary combination of essential oils from Mentha x piperita L. and Carum carvi. Because these oils exhibit antifungal and antibacterial properties, we investigated whether Menthacarin^® can reverse existing visceral hypersensitivity in maternally separated rats.

METHODS

In non-handled and maternally separated rats, we used the visceromotor responses to colorectal distension as measure for visceral sensitivity. We evaluated this response before and 24 hours after water-avoidance stress and after 7 days treatment with Menthacarin^® or control. The pre- and post-treatment mycobiome and microbiome were characterized by sequencing of fungal internal transcribed spacer 1 (ITS-1) and bacterial 16s rDNA regions. In vitro antifungal and antimicrobial properties of Menthacarin^® were studied with radial diffusion assay.

KEY RESULTS

Menthacarin^® inhibited in vitro growth of yeast and bacteria. Water-avoidance caused visceral hypersensitivity in maternally separated rats, and this was reversed by treatment. Multivariate analyses of ITS-1 and 16S high throughput data showed that maternal separation, induced changes in the myco- and microbiome. Menthacarin^® treatment of non-handled and maternally separated rats shifted the mycobiomes to more similar compositions.

CONCLUSIONS & INFERENCES

The development of visceral hypersensitivity in maternally separated rats and the Menthacarin^® -mediated reversal of hypersensitivity is associated with changes in the mycobiome. Therefore, Menthacarin^® may be a safe and effective treatment option that should be tested for IBS.

Effectiveness of Menthacarin on symptoms of irritable bowel syndrome

Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are common functional gastrointestinal disorders with overlapping symptoms. Effectiveness and safety of Menthacarin (Menthacarin® is the active ingredient of the product Carmenthin® [Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany]) in FD treatment were already demonstrated. We assessed the effectiveness of Menthacarin in reducing concomitant IBS-associated symptoms in FD patients. A systematic search to identify eligible double-blind, randomized controlled trials (RCTs) investigating Menthacarin in FD patients and focusing on IBS-associated symptoms was performed. Three out of five identified RCTs included a total of 111 eligible subjects, which allowed for summary statistics and inclusion into subgroup analysis for FD patients with IBS-associated symptoms. With pain intensity values decreasing by 50–75% on average during 28 days of treatment in patients with accompanying IBS, the subgroup analysis indicates beneficial treatment effects of Menthacarin that are similar to those found for FD patients in the primary analyses. The reduction of IBS-associated symptoms in FD patients suggests Menthacarin as a treatment option for IBS patients.

Definition, Pathogenesis, and Management of That Cursed Dyspepsia

Dyspepsia is an umbrella term used to encompass a number of symptoms thought to originate from the upper gastrointestinal tract. These symptoms are relatively nonspecific; not surprisingly, therefore, a myriad of conditions may present with any one or a combination of these symptoms. Therein lays the clinician's first challenge: detecting the minority who may have a potentially life-threatening disorder, such as gastric cancer, from a population whose symptoms are, for the most part, considered functional in origin. The second challenge lies in the definition and management of those individuals with functional dyspepsia (FD); the major focus of this review. The Rome process has addressed the issue of FD definition and a look back at the evolution of Rome criteria for this disorder illustrates the complexities that have so frustrated us. There has been no shortage of hypotheses to explain symptom pathogenesis in FD; initially focused on gastric sensorimotor dysfunction, these have now strayed well into the duodenum and have come to entertain such factors as immune responses and the microbiome. FD has proven to be an equally challenging area for therapeutics; while the staple approaches of acid suppression and eradication of Helicobacter pylori have some limited efficacy in select populations, strategies to ameliorate symptoms in the majority of sufferers based on presumed pathophysiology have largely foundered. Lacking a validated biomarker(s) FD continues to be an elusive target and is likely to remain so until we can better define the various phenotypes that it must surely contain.

Review article: the physiological effects and safety of peppermint oil and its efficacy in irritable bowel syndrome and other functional disorders

BACKGROUND

Peppermint oil has been used for centuries as a treatment for gastrointestinal ailments. It has been shown to have several effects on gastrointestinal physiology relevant to clinical care and management.

AIM

To review the literature on peppermint oil regarding its metabolism, effects on gastrointestinal physiology, clinical use and efficacy, and safety.

METHODS

We performed a PubMed literature search using the following terms individually or in combination: peppermint, peppermint oil, pharmacokinetics, menthol, oesophagus, stomach, small intestine, gallbladder, colon, transit, dyspepsia, nausea, abdominal pain, and irritable bowel syndrome. Full manuscripts evaluating peppermint oil that were published through 15 July 2017 were reviewed. When evaluating therapeutic indications, only randomised clinical trials were included. References from selected manuscripts were used if relevant.

RESULTS

It appears that peppermint oil may have several mechanisms of action including: smooth muscle relaxation (via calcium channel blockade or direct enteric nervous system effects); visceral sensitivity modulation (via transient receptor potential cation channels); anti-microbial effects; anti-inflammatory activity; modulation of psychosocial distress. Peppermint oil has been found to affect oesophageal, gastric, small bowel, gall-bladder, and colonic physiology. It has been used to facilitate completion of colonoscopy and endoscopic retrograde cholangiopancreatography. Placebo controlled studies support its use in irritable bowel syndrome, functional dyspepsia, childhood functional abdominal pain, and post-operative nausea. Few adverse effects have been reported in peppermint oil trials.

CONCLUSION

Peppermint oil is a natural product which affects physiology throughout the gastrointestinal tract, has been used successfully for several clinical disorders, and appears to have a good safety profile.