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Abdullah N, Kueh YC, Kuan G, Wong MS, Tee V, Tengku Alang TAI, Hamid N, Lee YY. Structural equation models of health behaviour, psychological well-being, symptom severity and quality of life in abdominal bloating. PeerJ 2024; 12:e17265. [PMID: 38708340 PMCID: PMC11067892 DOI: 10.7717/peerj.17265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/28/2024] [Indexed: 05/07/2024] Open
Abstract
Background The objective of this study was to investigate the inter-relationship between psychosocial variables and their impact on symptom severity and quality of life (QoL) concerning abdominal bloating. Methods The study adopted a cross-sectional design with purposive sampling. Participants who consented and met the criteria for bloating based on the Rome IV classification completed designated questionnaires. Independent variables comprised health beliefs, intentions, health-promoting behaviors, social support, depression, and anxiety, while dependent variables included bloating severity (general and within 24 h) and QoL. Structural Equation Modeling (SEM) was conducted utilizing Mplus 8.0 to analyze the relationships between these factors. Results A total of 323 participants, with a mean age of 27.69 years (SD = 11.50), predominantly females (64.7%), volunteered to participate in the study. The final SEM model exhibited good fit based on various indices (CFI = 0.922, SRMR = 0.064, RMSEA (95% CI) = 0.048 (0.041-0.054), p-value = 0.714), with 15 significant path relationships identified. The model explained 12.0% of the variance in severity within 24 h, 6% in general severity, and 53.8% in QoL. Conclusion The findings underscore the significant influence of health beliefs, intentions, behaviors, social support, depression, and anxiety on symptom severity and QoL in individuals experiencing abdominal bloating.
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Affiliation(s)
- Nurzulaikha Abdullah
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Faculty of Data Science and Computing, Universiti Malaysia Kelantan, Kota Bharu, Kelantan, Malaysia
| | - Yee Cheng Kueh
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Garry Kuan
- Exercise and Sport Science, School of Health Sciences, Universiti Sains Malaysia, Kelantan, Kubang Kerian, Malaysia
| | - Mung Seong Wong
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Vincent Tee
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | | | - Nurhazwani Hamid
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Yeong Yeh Lee
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- GI & Motility Unit, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Di Nardo G, Barbara G, Borrelli O, Cremon C, Giorgio V, Greco L, La Pietra M, Marasco G, Pensabene L, Piccirillo M, Romano C, Salvatore S, Saviano M, Stanghellini V, Strisciuglio C, Tambucci R, Turco R, Zenzeri L, Staiano A. Italian guidelines for the management of irritable bowel syndrome in children and adolescents : Joint Consensus from the Italian Societies of: Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP), Pediatrics (SIP), Gastroenterology and Endoscopy (SIGE) and Neurogastroenterology and Motility (SINGEM). Ital J Pediatr 2024; 50:51. [PMID: 38486305 PMCID: PMC10938778 DOI: 10.1186/s13052-024-01607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/11/2024] [Indexed: 03/18/2024] Open
Abstract
The irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID), whose prevalence has widely increased in pediatric population during the past two decades. The exact pathophysiological mechanism underlying IBS is still uncertain, thus resulting in challenging diagnosis and management. Experts from 4 Italian Societies participated in a Delphi consensus, searching medical literature and voting process on 22 statements on both diagnosis and management of IBS in children. Recommendations and levels of evidence were evaluated according to the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was reached for all statements. These guidelines suggest a positive diagnostic strategy within a symptom-based approach, comprehensive of psychological comorbidities assessment, alarm signs and symptoms' exclusion, testing for celiac disease and, under specific circumstances, fecal calprotectin and C-reactive protein. Consensus also suggests to rule out constipation in case of therapeutic failure. Conversely, routine stool testing for enteric pathogens, testing for food allergy/intolerance or small intestinal bacterial overgrowth are not recommended. Colonoscopy is recommended only in patients with alarm features. Regarding treatment, the consensus strongly suggests a dietary approach, psychologically directed therapies and, in specific conditions, gut-brain neuromodulators, under specialist supervision. Conditional recommendation was provided for both probiotics and specific fibers supplementation. Polyethylene glycol achieved consensus recommendation for specific subtypes of IBS. Secretagogues and 5-HT4 agonists are not recommended in children with IBS-C. Certain complementary alternative therapies, antispasmodics and, in specific IBS subtypes, loperamide and rifaximin could be considered.
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Affiliation(s)
- Giovanni Di Nardo
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Osvaldo Borrelli
- Neurogastroenterology & Motility Unit, Gastroenterology Department, Great Ormond Street Hospital for Children, London, UK
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Valentina Giorgio
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luigi Greco
- General Pediatrician, Heath Care Agency of Bergamo, Bergamo, Italy
| | | | - Giovanni Marasco
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, Magna Graecia University, Catanzaro, Italy
| | - Marisa Piccirillo
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Silvia Salvatore
- Pediatric Department, "F. Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Michele Saviano
- General Pediatrician, Heath Care Agency of Naples, Naples, Italy
| | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rossella Turco
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Letizia Zenzeri
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University Federico II, Via S. Pansini 5, Naples, 80131, Italy.
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3
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Rexwinkel R, Vlieger AM, Saps M, Tabbers MM, Benninga MA. A therapeutic guide on pediatric irritable bowel syndrome and functional abdominal pain-not otherwise specified. Eur J Pediatr 2022; 181:2603-2617. [PMID: 35460383 PMCID: PMC9192445 DOI: 10.1007/s00431-022-04459-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 12/14/2022]
Abstract
Disorders of the gut-brain interaction negatively impact quality of life and carry a substantial socioeconomic burden. Irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) are common functional abdominal pain disorders in childhood. The pathophysiology is not fully understood, and high-quality intervention trials and international guidelines are missing. Therefore, the management of these disorders remains challenging. This review aims to provide an up-to-date overview of therapeutic possibilities for pediatric IBS or FAP-NOS and recommends management strategies. To prevent unnecessary referrals and extensive costs, it is fundamental to make a positive diagnosis of IBS or FAP-NOS in children with chronic abdominal pain with only minimal investigations. A tailor-made approach for each patient, based on the accompanying physical and psychological symptoms, is proposed to date. CONCLUSION Shared decision-making including non-pharmacological and pharmacological interventions should be considered and discussed with the family. WHAT IS KNOWN • Irritable bowel syndrome and functional abdominal pain-not otherwise specified are common in childhood. • Although the number of treatment options has grown recently, managing these disorders can be challenging and unsatisfactory, and no evidence-based international management guidelines are available. WHAT IS NEW • We suggest using a stepwise individualized approach to management, where after first-line management, both non-pharmacological and pharmacological interventions should be discussed.
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Affiliation(s)
- Robyn Rexwinkel
- Emma Children's Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, Room C2-312, PO Box 22700, 1100 DD, Amsterdam, Netherlands.
| | - Arine M Vlieger
- Department of Pediatrics, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Miguel Saps
- Department of Pediatric Gastroenterology, University of Miami, Miami, FL, USA
| | - Merit M Tabbers
- Emma Children's Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, Room C2-312, PO Box 22700, 1100 DD, Amsterdam, Netherlands
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, Room C2-312, PO Box 22700, 1100 DD, Amsterdam, Netherlands
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Willits AB, Grossi V, Glidden NC, Hyams JS, Young EE. Identification of a Pain-Specific Gene Expression Profile for Pediatric Recurrent Abdominal Pain. Front Pain Res (Lausanne) 2022; 2:759634. [PMID: 35295473 PMCID: PMC8915586 DOI: 10.3389/fpain.2021.759634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Functional Abdominal Pain (FAP) and Irritable Bowel Syndrome (IBS) are common recurrent abdominal pain diagnoses with the hallmark, lack of inflammation. To identify a biological signature for IBS/FAP in the colon, this study used genetic profiling to uncover gene expression changes associated with IBS/FAP and abdominal pain. Methods: Patients (8 to 17 years) newly diagnosed with IBS or FAP were enrolled in the study. At diagnostic colonoscopy, three rectal biopsies were collected, and gene expression analysis was performed using a Qiagen PCR Array. Relative fold difference in gene expression for 84 pain-associated genes was calculated using the 2-ΔΔ Cq method compared with pain-free controls. Factors affecting pain burden (Pain Burden Interview; PBI) were analyzed, including age, sex, rectal inflammation, and gene expression. Data were analyzed using multiple stepwise linear regression and 2-tailed t tests (P ≤ 0.05). Results: Of the 22 total patients in the study, 19 were diagnosed with either IBS-Constipation (frequency of 5.26%), IBS-Diarrhea (47.37%), IBS-Mixed (10.53%), or FAP (36.84%). IBS/FAP patients reported significantly higher pain burden at the time of diagnosis compared to pain-free controls (p < 0.001), as well as significantly higher abdominal pain (p = 0.01). Of the 84 genes, expression of GRIN1 (p = 0.02), MAPK3 (p = 0.04), P2X4 (p = 0.04), and PTGES3 (p = 0.02) were all significantly associated with PBI score. Discussion: Abdominal pain associated with IBS/FAP in pediatric patients may be linked to the expression of GRIN1, MAPK3, P2X4, and PTGES3, pointing to potential novel therapeutic targets for management of recurring abdominal pain.
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Affiliation(s)
- Adam B Willits
- Neuroscience Program, KU Medical Center, Kansas City, KS, United States
| | - Victoria Grossi
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, United States
| | - Nicole C Glidden
- Genetics and Genome Sciences, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, United States
| | - Erin E Young
- Neuroscience Program, KU Medical Center, Kansas City, KS, United States.,Genetics and Genome Sciences, University of Connecticut School of Medicine, Farmington, CT, United States.,Department of Anesthesiology, KU Medical Center, Kansas City, KS, United States
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5
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Layer P, Andresen V, Allescher H, Bischoff SC, Claßen M, Elsenbruch S, Freitag M, Frieling T, Gebhard M, Goebel-Stengel M, Häuser W, Holtmann G, Keller J, Kreis ME, Kruis W, Langhorst J, Jansen PL, Madisch A, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Raithel M, Röhrig-Herzog G, Schemann M, Schmiedel S, Schwille-Kiuntke J, Storr M, Preiß JC, Andus T, Buderus S, Ehlert U, Engel M, Enninger A, Fischbach W, Gillessen A, Gschossmann J, Gundling F, Haag S, Helwig U, Hollerbach S, Karaus M, Katschinski M, Krammer H, Kuhlbusch-Zicklam R, Matthes H, Menge D, Miehlke S, Posovszky MC, Schaefert R, Schmidt-Choudhury A, Schwandner O, Schweinlin A, Seidl H, Stengel A, Tesarz J, van der Voort I, Voderholzer W, von Boyen G, von Schönfeld J, Wedel T. Update S3-Leitlinie Reizdarmsyndrom: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM) – Juni 2021 – AWMF-Registriernummer: 021/016. Z Gastroenterol 2021; 59:1323-1415. [PMID: 34891206 DOI: 10.1055/a-1591-4794] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - V Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - H Allescher
- Zentrum für Innere Medizin, Gastroent., Hepatologie u. Stoffwechsel, Klinikum Garmisch-Partenkirchen, Garmisch-Partenkirchen, Deutschland
| | - S C Bischoff
- Institut für Ernährungsmedizin, Universität Hohenheim, Stuttgart, Deutschland
| | - M Claßen
- Klinik für Kinder- und Jugendmedizin, Klinikum Links der Weser, Bremen, Deutschland
| | - S Elsenbruch
- Klinik für Neurologie, Translational Pain Research Unit, Universitätsklinikum Essen, Essen, Deutschland.,Abteilung für Medizinische Psychologie und Medizinische Soziologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - M Freitag
- Abteilung Allgemeinmedizin Department für Versorgungsforschung, Universität Oldenburg, Oldenburg, Deutschland
| | - T Frieling
- Medizinische Klinik II, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - M Gebhard
- Gemeinschaftspraxis Pathologie-Hamburg, Hamburg, Deutschland
| | - M Goebel-Stengel
- Innere Medizin II, Helios Klinik Rottweil, Rottweil, und Innere Medizin VI, Psychosomat. Medizin u. Psychotherapie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - W Häuser
- Innere Medizin I mit Schwerpunkt Gastroenterologie, Klinikum Saarbrücken, Saarbrücken, Deutschland
| | - G Holtmann
- Faculty of Medicine & Faculty of Health & Behavioural Sciences, Princess Alexandra Hospital, Brisbane, Australien
| | - J Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg, Deutschland
| | - P Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - A Madisch
- Klinik für Gastroenterologie, interventionelle Endoskopie und Diabetologie, Klinikum Siloah, Klinikum Region Hannover, Hannover, Deutschland
| | - H Mönnikes
- Klinik für Innere Medizin, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | | | - B Niesler
- Abteilung Molekulare Humangenetik Institut für Humangenetik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Pehl
- Medizinische Klinik, Krankenhaus Vilsbiburg, Vilsbiburg, Deutschland
| | - D Pohl
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - M Raithel
- Medizinische Klinik II m.S. Gastroenterologie und Onkologie, Waldkrankenhaus St. Marien, Erlangen, Deutschland
| | | | - M Schemann
- Lehrstuhl für Humanbiologie, TU München, Deutschland
| | - S Schmiedel
- I. Medizinische Klinik und Poliklinik Gastroenterologie, Universitätsklinikum Hamburg-Eppendorf, Deutschland
| | - J Schwille-Kiuntke
- Abteilung für Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik Tübingen, Tübingen, Deutschland.,Institut für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - M Storr
- Zentrum für Endoskopie, Gesundheitszentrum Starnberger See, Starnberg, Deutschland
| | - J C Preiß
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Berlin, Deutschland
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Pesce M, Puoti MG, Rybak A, Andreozzi M, Bruzzese E, Sarnelli G, Borrelli O. Pharmacological interventions for pediatric irritable bowel syndrome. Expert Opin Pharmacother 2021; 23:91-103. [PMID: 34523358 DOI: 10.1080/14656566.2021.1976753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Irritable bowel syndrome is a common functional gastrointestinal disorder in children, characterized by recurrent abdominal pain associated with altered bowel habits in terms of both frequency and consistency. According to change in stool consistency it is categorized into 4 subtypes. From the etiological perspective, it is a combination of factors takes part in symptoms' generation, the overall treatment response rate is often unsatisfactory if a multidisciplinary is not pursued. AREAS COVERED The aim of this manuscript is to summarize the current pharmacotherapy in pediatric irritable bowel syndrome in order to aid clinicians in treating this challenging disorder. EXPERT OPINION Most evidence involving pediatric populations rely on open label or retrospective studies and/or are not specifically designed for irritable bowel syndrome but tend to generalize their results to mixed populations of children with functional gastrointestinal disorders. A high placebo response rate combined with poor patients' selection could account for the overall weak evidence supporting the use of pharmacological agents in pediatric irritable bowel syndrome. Given the multifaceted nature of the disorder, multidisciplinary approaches combining pharmacotherapy with alternative treatments is highly recommendable.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico Ii" of Naples, Naples, Italy
| | - Maria Giovanna Puoti
- Division of Neurogastroenterology & Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for children, London, UK
| | - Anna Rybak
- Division of Neurogastroenterology & Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for children, London, UK
| | - Marta Andreozzi
- Department of Clinical Medicine and Surgery, University "Federico Ii" of Naples, Naples, Italy
| | - Eugenia Bruzzese
- Department of Translational Medical Science, University "Federico Ii" of Naples, Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University "Federico Ii" of Naples, Naples, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology & Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for children, London, UK
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Friesen C, Colombo JM, Deacy A, Schurman JV. An Update on the Assessment and Management of Pediatric Abdominal Pain. Pediatric Health Med Ther 2021; 12:373-393. [PMID: 34393542 PMCID: PMC8354769 DOI: 10.2147/phmt.s287719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/15/2021] [Indexed: 12/12/2022]
Abstract
Chronic abdominal pain is very common in children and adolescent and results in high personal and social costs. Most youth with chronic abdominal pain fulfill criteria for a functional abdominal pain disorder (FAPD) as defined by Rome criteria. These are complex conditions with a wide array of biological, psychological, and social factors contributing to the experience of pain. The purpose of the current review is to provide an overview of the pathophysiology of FAPDs and an up-to-date summary of the literature related to FAPDs in children and adolescents, with additional focus on several areas (eg, diet and probiotics) where patients and families frequently have questions or implement self-directed care. We also provide an approach to the assessment and treatment of pediatric FAPDs focusing on the robust literature regarding psychological interventions and much sparser literature regarding medication treatment.
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Affiliation(s)
- Craig Friesen
- Division of Gastroenterology, Hepatology, and Nutrition; Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jennifer M Colombo
- Division of Gastroenterology, Hepatology, and Nutrition; Children's Mercy Kansas City, Kansas City, MO, USA
| | - Amanda Deacy
- Division of Gastroenterology, Hepatology, and Nutrition; Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jennifer V Schurman
- Division of Gastroenterology, Hepatology, and Nutrition; Children's Mercy Kansas City, Kansas City, MO, USA
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Abdullah N, Kueh YC, Kuan G, Wong MS, Yahaya FH, Abd Samat NA, Zulkifli KK, Lee YY. Development and validation of the Health Promoting Behaviour for Bloating (HPB-Bloat) scale. PeerJ 2021; 9:e11444. [PMID: 34141467 PMCID: PMC8183425 DOI: 10.7717/peerj.11444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 04/21/2021] [Indexed: 12/04/2022] Open
Abstract
Background Health management strategies may help patients with abdominal bloating (AB), but there are currently no tools that measure behaviour and awareness. This study aimed to validate and verify the dimensionality of the newly-developed Health Promoting Behaviour for Bloating (HPB-Bloat) scale. Methods Based on previous literature, expert input, and in-depth interviews, we generated new items for the HPB-Bloat. Its content validity was assessed by experts and pre-tested across 30 individuals with AB. Construct validity and dimensionality were first determined using exploratory factor analysis (EFA) and Promax rotation analysis, and then using confirmatory factor analysis (CFA). Results During the development stage, 35 items were generated for the HPB-Bloat, and were maintained following content validity assessment and pre-testing. One hundred and fifty-two participants (mean age of 31.27 years, 68.3% female) and 323 participants (mean age of 27.69 years, 59.4% male) completed the scale for EFA and CFA, respectively. Using EFA, we identified 20 items that we divided into five factors: diet (five items), health awareness (four items), physical activity (three items), stress management (four items), and treatment (four items). The total variance explained by the EFA model was 56.7%. The Cronbach alpha values of the five factors ranged between 0.52 and 0.81. In the CFA model, one problematic latent variable (treatment) was identified and three items were removed. In the final measurement model, four factors and 17 items fit the data well based on several fit indices (root mean square error of approximation (RMSEA) = 0.044 and standardized root mean squared residual (SRMR) = 0.052). The composite reliability of all factors in the final measurement model was above 0.60, indicating acceptable construct reliability. Conclusion The newly developed HPB-Bloat scale is valid and reliable when assessing the awareness of health-promoting behaviours across patients with AB. Further validation is needed across different languages and populations.
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Affiliation(s)
- Nurzulaikha Abdullah
- Biostatistics & Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Yee Cheng Kueh
- Biostatistics & Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Garry Kuan
- Exercise and Sport Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Department of Life Sciences, Brunel University, London, United Kingdom
| | - Mung Seong Wong
- Department of Medicine, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,GI Function & Motility Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | | | - Nor Aslina Abd Samat
- Department of Medicine, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,GI Function & Motility Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Khairil Khuzaini Zulkifli
- GI Function & Motility Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Yeong Yeh Lee
- Department of Medicine, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,GI Function & Motility Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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9
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Rexwinkel R, de Bruijn CMA, Gordon M, Benninga MA, Tabbers MM. Pharmacologic Treatment in Functional Abdominal Pain Disorders in Children: A Systematic Review. Pediatrics 2021; 147:peds.2020-042101. [PMID: 34045320 DOI: 10.1542/peds.2020-042101] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Functional abdominal pain disorders (FAPDs) are common in childhood, impacting quality of life and school attendance. There are several compounds available for the treatment of pediatric FAPDs, but their efficacy and safety are unclear because of a lack of head-to-head randomized controlled trials (RCTs). OBJECTIVE To systematically review the efficacy and safety of the pharmacologic treatments available for pediatric FAPDs. DATA SOURCES Electronic databases were searched from inception to February 2021. STUDY SELECTION RCTs or systematic reviews were included if the researchers investigated a study population of children (4-18 years) in whom FAPDs were treated with pharmacologic interventions and compared with placebo, no treatment, or any other agent. DATA EXTRACTION Two reviewers independently performed data extraction and assessed their quality. Any interresearcher disagreements in the assessments were resolved by a third investigator. RESULTS Seventeen articles representing 1197 children with an FAPD were included. Trials investigating antispasmodics, antidepressants, antibiotics, antihistaminic, antiemetic, histamine-2-receptor antagonist, 5-HT4-receptor agonist, melatonin, and buspirone were included. No studies were found on treatment with laxatives, antidiarrheals, analgesics, antimigraines, and serotonergics. LIMITATIONS The overall quality of evidence on the basis of the Grading of Recommendations, Assessment, Development and Evaluations system was very low to low. CONCLUSIONS On the basis of current evidence, it is not possible to recommend any specific pharmacologic agent for the treatment of pediatric FAPDs. However, agents such as antispasmodics or antidepressants can be discussed in daily practice because of their favorable treatment outcomes and the lack of important side effects. High-quality RCTs are necessary to provide adequate pharmacologic treatment. For future intervention trials, we recommend using homogenous outcome measures and instruments, a large sample size, and long-term follow-up.
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Affiliation(s)
- Robyn Rexwinkel
- Pediatric Gastroenterology, Hepatology, and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; .,Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Academic Medical Center and Emma Children's Hospital, Amsterdam, The Netherlands.,Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and.,Contributed equally as co-first authors
| | - Clara M A de Bruijn
- Pediatric Gastroenterology, Hepatology, and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Academic Medical Center and Emma Children's Hospital, Amsterdam, The Netherlands.,Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and.,Contributed equally as co-first authors
| | - Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Marc A Benninga
- Pediatric Gastroenterology, Hepatology, and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Merit M Tabbers
- Pediatric Gastroenterology, Hepatology, and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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10
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Lacy BE, Pimentel M, Brenner DM, Chey WD, Keefer LA, Long MD, Moshiree B. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastroenterol 2021; 116:17-44. [PMID: 33315591 DOI: 10.14309/ajg.0000000000001036] [Citation(s) in RCA: 293] [Impact Index Per Article: 97.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.
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11
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Zeevenhooven J, Timp ML, Singendonk MMJ, Benninga MA, Tabbers MM. Definitions of Pediatric Functional Abdominal Pain Disorders and Outcome Measures: A Systematic Review. J Pediatr 2019; 212:52-59.e16. [PMID: 31277898 DOI: 10.1016/j.jpeds.2019.04.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/19/2019] [Accepted: 04/24/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To systematically review definitions of functional abdominal pain orders (FAPDs) and outcome measures used in therapeutic randomized controlled trials in pediatric FAPDs adhering to the Outcome Measures in Rheumatology recommendations. STUDY DESIGN Cochrane, MEDLINE, Embase, and Cinahl databases were systematically searched from inception to April 2018. English-written therapeutic randomized controlled trials concerning FAPDs in children aged 4-18 years were included. Definitions of FAPDs, interventions, outcome measures, measurement instruments, and outcome assessors of each study were tabulated descriptively. Quality was assessed using the Delphi List. RESULTS A total of 4771 articles were found, of which 64 articles were included (n = 25, 39% of high methodologic quality). The Rome III (50%), Rome II (17%), Apley (16%), and author-defined (17%) criteria were used to define FAPDs. Fourteen studies (22%) assessed a pharmacologic, 25 (39%) a dietary, and 25 (39%) a psychosocial intervention. Forty-four studies (69%) predefined their primary outcomes. In total, 211 reported predefined outcome measures were grouped into 23 different outcome domains; the majority being patient-reported (n = 27, 61%). Of the 14 studies that evaluated a pharmacologic intervention, 12 (86%) reported on adverse events. CONCLUSIONS Studies on pediatric FAPDs are of limited methodologic quality and show large heterogeneity and inconsistency in defining FAPDs and outcome measures used. Development of a core outcome set is needed to make comparison between intervention studies possible.
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Affiliation(s)
- Judith Zeevenhooven
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, the Netherlands.
| | - Merel L Timp
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, the Netherlands
| | - Maartje M J Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, the Netherlands
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, the Netherlands
| | - Merit M Tabbers
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, the Netherlands
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12
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Eccleston C, Fisher E, Cooper TE, Grégoire MC, Heathcote LC, Krane E, Lord SM, Sethna NF, Anderson AK, Anderson B, Clinch J, Gray AL, Gold JI, Howard RF, Ljungman G, Moore RA, Schechter N, Wiffen PJ, Wilkinson NMR, Williams DG, Wood C, van Tilburg MAL, Zernikow B. Pharmacological interventions for chronic pain in children: an overview of systematic reviews. Pain 2019; 160:1698-1707. [PMID: 31335640 DOI: 10.1097/j.pain.0000000000001609] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We know little about the safety or efficacy of pharmacological medicines for children and adolescents with chronic pain, despite their common use. Our aim was to conduct an overview review of systematic reviews of pharmacological interventions that purport to reduce pain in children with chronic noncancer pain (CNCP) or chronic cancer-related pain (CCRP). We searched the Cochrane Database of Systematic Reviews, Medline, EMBASE, and DARE for systematic reviews from inception to March 2018. We conducted reference and citation searches of included reviews. We included children (0-18 years of age) with CNCP or CCRP. We extracted the review characteristics and primary outcomes of ≥30% participant-reported pain relief and patient global impression of change. We sifted 704 abstracts and included 23 systematic reviews investigating children with CNCP or CCRP. Seven of those 23 reviews included 6 trials that involved children with CNCP. There were no randomised controlled trials in reviews relating to reducing pain in CCRP. We were unable to combine data in a meta-analysis. Overall, the quality of evidence was very low, and we have very little confidence in the effect estimates. The state of evidence of randomized controlled trials in this field is poor; we have no evidence from randomised controlled trials for pharmacological interventions in children with cancer-related pain, yet cannot deny individual children access to potential pain relief. Prospero ID: CRD42018086900.
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Affiliation(s)
- Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Pain, Palliative, and Supportive Care, Oxford University Hospitals, Oxford, United Kingdom
| | - Tess E Cooper
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Lauren C Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Elliot Krane
- Department of Anesthesiology, Perioperative, and Pain Medicine, Pediatrics, Stanford University School of Medicine, Stanford, Palo Alto, CA, United States
| | - Susan M Lord
- Children's Complex Pain Service, John Hunter Children's Hospital, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Navil F Sethna
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | | | - Brian Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Jacqueline Clinch
- Bristol Royal Children's Hospital, University of Bristol, Bristol, United Kingdom
- Royal National Hospital for Rheumatic Diseases, Bath, United Kingdom
| | - Andrew L Gray
- Division of Pharmacology, Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jeffrey I Gold
- Anesthesiology, Pediatrics, and Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Pediatric Pain Management Clinic, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - Gustaf Ljungman
- Pediatric Oncology, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - R Andrew Moore
- Pain Research, Nuffield, Department of Clinical Neurosciences, University of Oxford, The Churchill, Oxford, United Kingdom
| | - Neil Schechter
- Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Philip J Wiffen
- Pain Research, Nuffield, Department of Clinical Neurosciences, University of Oxford, The Churchill, Oxford, United Kingdom
| | - Nick M R Wilkinson
- Department of Paediatrics, Evelina London Children's Hospital, Kings College London, United Kingdom
| | - David G Williams
- The Anaesthetic Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Chantal Wood
- Department of Rheumatology, Chronic Pain Centre, University Hospital of Limoges, University of Limoges, Haute Vienne, France
| | - Miranda A L van Tilburg
- College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC, United States
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, United States
| | - Boris Zernikow
- German Paediatric Pain Centre, Children's and Adolescent's Hospital, Datteln, Germany
- Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
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13
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Rexwinkel R, Zeevenhooven J, van Etten-Jamaludin FS, Benninga MA, Tabbers MM. Side effects associated with pharmacotherapy for pediatric irritable bowel syndrome and functional abdominal pain - not otherwise specified: a systematic review. Expert Opin Drug Saf 2019; 18:111-125. [PMID: 30676113 DOI: 10.1080/14740338.2019.1574295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION To systematically review the literature regarding the side effects of pharmacotherapy in children with irritable bowel syndrome (IBS) and functional abdominal pain - not otherwise specified (FAP-NOS). Areas covered: Cochrane Library, PubMed, and Embase databases were searched from inception to May 2018. The following inclusion criteria were applied: (1) randomized controlled trials (RCTs), cohort studies or case-control studies; (2) in children aged 4-18 years or adult studies if children are reported separately; (3) reporting a diagnosis of IBS or FAP-NOS as defined by the authors; and (4) reporting the occurrence of side effects of pharmacotherapy. Quality assessment of included studies was conducted. Expert opinion: A total of 4619 articles were identified; 17 were included. In 10/17 (59%) studies, side effects of pharmacotherapy (antispasmodics, antidepressants, antihistaminic agents, serotonergic agents and antibiotics) occurred. The majority of side effects were: (1) limited to the gastrointestinal tract and central nervous system and, 2) mild and transient. No serious adverse events were reported. This systematic review shows that data on safety in children with functional abdominal pain disorders are scarce, and highlights the lack of high-quality research for potential side effects of pediatric IBS and FAP-NOS. Further research by means of large well-designed-follow-up studies is necessary.
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Affiliation(s)
- Robyn Rexwinkel
- a Pediatric Gastroenterology , Emma Children's Hospital, Amsterdam UMC, University of Amsterdam , Amsterdam , The Netherlands
| | - Judith Zeevenhooven
- a Pediatric Gastroenterology , Emma Children's Hospital, Amsterdam UMC, University of Amsterdam , Amsterdam , The Netherlands
| | | | - Marc A Benninga
- a Pediatric Gastroenterology , Emma Children's Hospital, Amsterdam UMC, University of Amsterdam , Amsterdam , The Netherlands
| | - Merit M Tabbers
- a Pediatric Gastroenterology , Emma Children's Hospital, Amsterdam UMC, University of Amsterdam , Amsterdam , The Netherlands
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14
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Kim JH, Jee SR. Irritable Bowel Syndrome. Korean J Gastroenterol 2019; 73:84-91. [DOI: 10.4166/kjg.2019.73.2.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/28/2019] [Accepted: 02/01/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Jae Hak Kim
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Sam Ryong Jee
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
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15
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Abbott RA, Martin AE, Newlove-Delgado TV, Bethel A, Whear RS, Thompson Coon J, Logan S. Recurrent Abdominal Pain in Children: Summary Evidence From 3 Systematic Reviews of Treatment Effectiveness. J Pediatr Gastroenterol Nutr 2018; 67:23-33. [PMID: 29470291 DOI: 10.1097/MPG.0000000000001922] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. METHODS We carried out a systematic review of randomised controlled trials (RCTs) in eleven databases and 2 trials registries from inception to June 2016. An update search was run in November 2017. All screening was performed by 2 independent reviewers. Included studies were appraised using the Cochrane risk of bias tool and the evidence assessed using GRADE. We included any dietary, pharmacological or psychosocial intervention for RAP, defined by Apley or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria, in children and adolescents. RESULTS We included 55 RCTs, involving 3572 children with RAP (21 dietary, 15 pharmacological, 19 psychosocial, and 1 multiarm). We found probiotic diets, cognitive-behavioural therapy (CBT) and hypnotherapy were reported to reduce pain in the short-term and there is some evidence of medium term effectiveness. There was insufficient evidence of effectiveness for all other dietary interventions and psychosocial therapies. There was no robust evidence of effectiveness for pharmacological interventions. CONCLUSIONS Overall the evidence base for treatment decisions is poor. These data suggest that probiotics, CBT, and hypnotherapy could be considered as part of holistic management of children with RAP. The evidence regarding relative effectiveness of different strains of probiotics is currently insufficient to guide clinical practice. The lack of evidence of effectiveness for any drug suggests that there is little justification for their use outside of well-conducted clinical trials. There is an urgent need for high-quality RCTs to provide evidence to guide management of this common condition.
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16
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Abstract
Recurrent abdominal pain (RAP) is one of the most common health complaints in both children and adults. Although RAP is considered a functional disorder rather than an organic disease, affected children and their families can still experience anxiety and concerns that can interfere with school, sports, and regular daily activities and lead to frequent attendances at pediatric emergency departments or pediatric gastroenterology clinics. Our review shows experts do not agree on a universally proven management that will work on every child presenting with functional abdominal pain (FAP). Treatment strategies include both non-pharmacological and pharmacological options. Non-pharmacological treatments are usually very well accepted by both children and their parents and are free from medication side effects. Nevertheless, they may be as effective as the pharmacological interventions; therefore, according to many experts and based on the majority of current evidence, a non-pharmacological approach should be the first intervention attempt in children with RAP. In particular, the importance of the bio-psychosocial approach is highlighted, as a majority of children will improve with counselling and reassurance that no serious organic pathologies are suspected, especially when the physician establishes a trustful relationship with both the child and their family. Placebo and pharmacological interventions could be attempted when the bio-psychosocial approach is not applicable or not efficacious. In some difficult cases, finding an effective treatment for FAP can be a challenge, and a number of strategies may need to be tried before symptoms are controlled. In these cases, a multidisciplinary team, comprising a pediatric gastroenterologist, dietician, psychologist, and psychotherapist, is likely to be successful.
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Affiliation(s)
- Andrea Brusaferro
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Edoardo Farinelli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Letizia Zenzeri
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Rita Cozzali
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy.
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Martin AE, Newlove‐Delgado TV, Abbott RA, Bethel A, Thompson‐Coon J, Whear R, Logan S. Pharmacological interventions for recurrent abdominal pain in childhood. Cochrane Database Syst Rev 2017; 3:CD010973. [PMID: 28262913 PMCID: PMC6464549 DOI: 10.1002/14651858.cd010973.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Between 4% and 25% of school-aged children at some stage complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with their daily lives. When no clear organic cause is found, the children are managed with reassurance and simple measures; a large range of pharmacological interventions have been recommended for use in these children. OBJECTIVES To determine the effectiveness of pharmacological interventions for RAP in children of school age. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase, and eight other electronic databases up to June 2016. We also searched two trials registers and contacted researchers of published studies. SELECTION CRITERIA Randomised controlled trials involving children aged five to 18 years old with RAP or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006). The interventions were any pharmacological intervention compared to placebo, no treatment, waiting list, or standard care. The primary outcome measures were pain intensity, pain duration or pain frequency, and improvement in pain. The secondary outcome measures were school performance, social or psychological functioning, and quality of daily life. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles, abstracts, and potentially relevant full-text reports for eligible studies. Two review authors extracted data and performed a 'Risk of bias' assessment. We used the GRADE approach to rate the overall quality of the evidence. We deemed a meta-analysis to be not appropriate as the studies were significantly heterogeneous. We have consequently provided a narrative summary of the results. MAIN RESULTS This review included 16 studies with a total of 1024 participants aged between five and 18 years, all of whom were recruited from paediatric outpatient clinics. Studies were conducted in seven countries: seven in the USA, four in Iran, and one each in the UK, Switzerland, Turkey, Sri Lanka, and India. Follow-up ranged from two weeks to four months. The studies examined the following interventions to treat RAP: tricyclic antidepressants, antibiotics, 5-HT4 receptor agonists, antispasmodics, antihistamines, H2 receptor antagonists, serotonin antagonists, selective serotonin re-uptake inhibitors, a dopamine receptor antagonist, and a hormone. Although some single studies reported that treatments were effective, all of these studies were either small or had key methodological weaknesses with a substantial risk of bias. None of these 'positive' results have been reproduced in subsequent studies. We judged the evidence of effectiveness to be of low quality. No adverse effects were reported in these studies. AUTHORS' CONCLUSIONS There is currently no convincing evidence to support the use of drugs to treat RAP in children. Well-conducted clinical trials are needed to evaluate any possible benefits and risks of pharmacological interventions. In practice, if a clinician chooses to use a drug as a 'therapeutic trial', they and the patient need to be aware that RAP is a fluctuating condition and any 'response' may reflect the natural history of the condition or a placebo effect, rather than drug efficacy.
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Affiliation(s)
- Alice E Martin
- Royal Devon and Exeter HospitalPaediatricsBarrack RoadExeterEnglandUKEX2 5DW
| | - Tamsin V Newlove‐Delgado
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusExeterEnglandUKEX1 2LU
| | - Rebecca A Abbott
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusExeterEnglandUKEX1 2LU
| | - Alison Bethel
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusExeterEnglandUKEX1 2LU
| | - Joanna Thompson‐Coon
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusExeterEnglandUKEX1 2LU
| | - Rebecca Whear
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusExeterEnglandUKEX1 2LU
| | - Stuart Logan
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusExeterEnglandUKEX1 2LU
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18
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Abstract
BACKGROUND Constipation within childhood is an extremely common problem. Despite the widespread use of osmotic and stimulant laxatives by health professionals to manage constipation in children, there has been a long standing paucity of high quality evidence to support this practice. OBJECTIVES We set out to evaluate the efficacy and safety of osmotic and stimulant laxatives used to treat functional childhood constipation. SEARCH METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialized Trials Register from inception to 10 March 2016. There were no language restrictions. We also searched the references of all included studies, personal contacts and drug companies to identify studies. SELECTION CRITERIA Randomised controlled trials (RCTs) which compared osmotic or stimulant laxatives to placebo or another intervention, with participants aged 0 to 18 years old were considered for inclusion. The primary outcome was frequency of defecation. Secondary endpoints included faecal incontinence, disimpaction, need for additional therapies and adverse events. DATA COLLECTION AND ANALYSIS Relevant papers were identified and two authors independently assessed the eligibility of trials, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was frequency of defecation. Secondary endpoints included faecal incontinence, disimpaction, need for additional therapies and adverse events. For continuous outcomes we calculated the mean difference (MD) and 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes we calculated the risk ratio (RR) and 95% CI using a fixed-effect model. The Chi(2) and I(2) statistics were used to assess statistical heterogeneity. A random-effects model was used in situations of unexplained heterogeneity. We assessed the overall quality of the evidence supporting the primary and secondary outcomes using the GRADE criteria. MAIN RESULTS Twenty-five RCTs (2310 participants) were included in the review. Fourteen studies were judged to be at high risk of bias due to lack of blinding, incomplete outcome data and selective reporting. Meta-analysis of two studies (101 patients) comparing polyethylene glycol (PEG) with placebo showed a significantly increased number of stools per week with PEG (MD 2.61 stools per week, 95% CI 1.15 to 4.08). Common adverse events in the placebo-controlled studies included flatulence, abdominal pain, nausea, diarrhoea and headache. Participants receiving high dose PEG (0.7 g/kg) had significantly more stools per week than low dose PEG (0.3 g/kg) participants (1 study, 90 participants, MD 1.30, 95% 0.76 to 1.84). Meta-analysis of 6 studies with 465 participants comparing PEG with lactulose showed a significantly greater number of stools per week with PEG (MD 0.70 , 95% CI 0.10 to 1.31), although follow-up was short. Patients who received PEG were significantly less likely to require additional laxative therapies. Eighteen per cent (27/154) of PEG patients required additional therapies compared to 31% (47/150) of lactulose patients (RR 0.55, 95% CI 0.36 to 0.83). No serious adverse events were reported with either agent. Common adverse events in these studies included diarrhoea, abdominal pain, nausea, vomiting and pruritis ani. Meta-analysis of 3 studies with 211 participants comparing PEG with milk of magnesia showed that the stools per week were significantly greater with PEG (MD 0.69, 95% CI 0.48 to 0.89). However, the magnitude of this difference was quite small and may not be clinically significant. One child was noted to be allergic to PEG, but there were no other serious adverse events reported. One study found a significant difference in stools per week favouring milk of magnesia over lactulose (MD -1.51, 95% CI -2.63 to -0.39, 50 patients), Meta-analysis of 2 studies with 287 patients comparing liquid paraffin (mineral oil) with lactulose revealed a relatively large statistically significant difference in the number of stools per week favouring liquid paraffin (MD 4.94 , 95% CI 4.28 to 5.61). No serious adverse events were reported. Adverse events included abdominal pain, distention and watery stools. No statistically significant differences in the number of stools per week were found between PEG and enemas (1 study, 90 patients, MD 1.00, 95% CI -1.58 to 3.58), dietary fibre mix and lactulose (1 study, 125 patients, P = 0.481), senna and lactulose (1 study, 21 patients, P > 0.05), lactitol and lactulose (1 study, 51 patients, MD -0.80, 95% CI -2.63 to 1.03), hydrolyzed guar gum and lactulose (1 study, 61 patients, MD 1.00, 95% CI -1.80 to 3.80), PEG and flixweed (1 study, 109 patients, MD 0.00, 95% CI -0.33 to 0.33), PEG and dietary fibre (1 study, 83 patients, MD 0.20, 95% CI -0.64 to 1.04), and PEG and liquid paraffin (2 studies, 261 patients, MD 0.35, 95% CI -0.24 to 0.95). AUTHORS' CONCLUSIONS The pooled analyses suggest that PEG preparations may be superior to placebo, lactulose and milk of magnesia for childhood constipation. GRADE analyses indicated that the overall quality of the evidence for the primary outcome (number of stools per week) was low or very low due to sparse data, inconsistency (heterogeneity), and high risk of bias in the studies in the pooled analyses. Thus, the results of the pooled analyses should be interpreted with caution because of quality and methodological concerns, as well as clinical heterogeneity, and short follow-up. There is also evidence suggesting the efficacy of liquid paraffin (mineral oil). There is no evidence to demonstrate the superiority of lactulose when compared to the other agents studied, although there is a lack of placebo controlled studies. Further research is needed to investigate the long term use of PEG for childhood constipation, as well as the role of liquid paraffin. The optimal dose of PEG also warrants further investigation.
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Affiliation(s)
- Morris Gordon
- University of Central LancashireSchool of MedicinePrestonLancashireUK
- Blackpool Victoria HospitalFamilies DivisionBlackpoolUK
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | | | - Adrian G Thomas
- Royal Manchester Children's HospitalOxford RoadManchesterUKM13 9WL
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Müller A, Franke H, Resch KL, Fryer G. Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review. J Osteopath Med 2015; 114:470-9. [PMID: 24917634 DOI: 10.7556/jaoa.2014.098] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Irritable bowel syndrome (IBS) is a common and often lifelong functional gastrointestinal disorder. There is a scarcity of effective management options for IBS. OBJECTIVE To assess the effectiveness of osteopathic manipulative therapy (OMTh) for managing the symptoms of IBS. DATA SOURCES Articles without language or publication-date restriction were searched in PubMed, Embase, Cochrane Library, PEDro, OSTMED.DR, and Osteopathic Research Web. Search terms included irritable bowel syndrome, IBS, functional colonic disease, colon irritable, osteopath*, osteopathic manipulation, osteopathic medicine, clinical trial, and randomized clinical trial. Experts in the field of visceral osteopathy were also contacted to identify additional studies. STUDY SELECTION The authors evaluated randomized controlled trials (RCTs) of OMTh for IBS in adults in whom IBS was diagnosed using Rome (I-III) criteria. If OMTh was not the sole intervention in the intervention group and if the same additional interventions were not applied to the control group, the study was excluded. DATA EXTRACTION Citation identification, study selection, and data extraction were independently undertaken by 2 reviewers with a data extraction form from the Cochrane Collaboration. A consensus method was used to resolve disagreements concerning the assessment of the methodologic quality of the RCTs that were reviewed. RESULTS The search identified 10 studies that examined OMTh for patients with IBS; 5 studies (204 patients) met the inclusion criteria. All studies were assessed as having low risk of bias according to the Cochrane Collaboration criteria, although there was heterogeneity in the outcome measures and control interventions. Three studies used visual analog scales for abdominal pain, whereas others used the IBS severity score and the Functional Bowel Disorder Severity Index. A variety of secondary outcomes were used. All studies reported more pronounced short-term improvements with OMTh compared with sham therapy or standard care only. These differences remained statistically significant after variable lengths of follow-up in 3 studies. CONCLUSION The present systematic review provides preliminary evidence that OMTh may be beneficial in the treatment of patients with IBS. However, caution is required in the interpretation of these findings because of the limited number of studies available and the small sample sizes.
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Affiliation(s)
- Axel Müller
- From the Institute for Osteopathic Studies in Siegen, Germany (Mr Müller and Mr Franke); the University of Dresden and German Institute for Health Research (Dr Resch); and the College of Health and Biomedicine and the Institute of Sport, Exercise and Active Living at Victoria University in Melbourne, Australia (Dr Fryer)
| | - Helge Franke
- From the Institute for Osteopathic Studies in Siegen, Germany (Mr Müller and Mr Franke); the University of Dresden and German Institute for Health Research (Dr Resch); and the College of Health and Biomedicine and the Institute of Sport, Exercise and Active Living at Victoria University in Melbourne, Australia (Dr Fryer)
| | - Karl-Ludwig Resch
- From the Institute for Osteopathic Studies in Siegen, Germany (Mr Müller and Mr Franke); the University of Dresden and German Institute for Health Research (Dr Resch); and the College of Health and Biomedicine and the Institute of Sport, Exercise and Active Living at Victoria University in Melbourne, Australia (Dr Fryer)
| | - Gary Fryer
- From the Institute for Osteopathic Studies in Siegen, Germany (Mr Müller and Mr Franke); the University of Dresden and German Institute for Health Research (Dr Resch); and the College of Health and Biomedicine and the Institute of Sport, Exercise and Active Living at Victoria University in Melbourne, Australia (Dr Fryer)
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Bokic T, Storr M, Schicho R. Potential Causes and Present Pharmacotherapy of Irritable Bowel Syndrome: An Overview. Pharmacology 2015; 96:76-85. [PMID: 26139425 DOI: 10.1159/000435816] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is currently one of the most common disorders of the digestive system in the Western society. Almost 2 out of 10 people suffer from IBS with women being more affected than men. IBS is associated with abdominal pain, bloating and altered stool consistency and imposes a heavy burden for the affected patients. SUMMARY The pathophysiology of IBS remains elusive although potential causes have been suggested, such as a deranged brain-gut signaling, hypersensitivity of visceral sensory afferent fibers, bacterial gastroenteritis, small intestinal bacterial overgrowth (SIBO), genetic alterations and food sensitivity. Targets for the pharmacotherapy of IBS include the serotonergic and opioidergic system, and the microbial population of the gut. Alternative therapies like traditional Chinese medicine have shown some success in the combat against IBS. Key Messages: Many therapeutics for the treatment of IBS have emerged in the past; however, only a few have met up with the expectations in larger clinical trials. Additionally, the multifactorial etiology of IBS and its variety of cardinal symptoms requires an individual set of therapeutics. This review provides a short overview of potential causes and current pharmacological therapeutics and of additional and alternative therapies for IBS.
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Affiliation(s)
- Theodor Bokic
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria
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21
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Arbuckle RA, Carson RT, Abetz-Webb L, Hyams J, Di Lorenzo C, Lewis BE, Gargon E, Kurtz C, Shiff SJ, Johnston JM. Measuring the symptoms of pediatric constipation and irritable bowel syndrome with constipation: expert commentary and literature review. Patient 2015; 7:343-64. [PMID: 24965712 DOI: 10.1007/s40271-014-0070-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Symptom measurement in pediatric chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) trials requires appropriately developed clinical outcome assessments (COAs). METHODS Literature was reviewed to identify symptom COAs meeting regulatory standards. Searches were conducted in Pubmed/Medline, EMBASE, and PsychINFO. Title/abstracts were reviewed to identify qualitative studies and those using COAs to measure pediatric CIC/IBS symptoms. Pediatric functional gastrointestinal experts provided input on relevant symptom-concepts to measure. RESULTS Review of 1,105 abstracts identified 1 relevant qualitative article and 113 articles including COAs. Symptoms most frequently measured in CIC studies were frequency of bowel movements, fecal incontinence/encopresis, abdominal pain, stool consistency, and painful defecation. Symptoms most frequently measured in IBS were abdominal pain, abdominal distention/bloating, stool consistency, frequency of bowel movements, and gas. Evidence of development/validity of COAs was limited. Expert feedback was broadly consistent with the literature. CONCLUSION Findings demonstrate consistency in the literature on key CIC/IBS symptoms to measure in pediatric trials, but existing COAs do not meet regulatory standards.
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Korterink JJ, Rutten JMTM, Venmans L, Benninga MA, Tabbers MM. Pharmacologic treatment in pediatric functional abdominal pain disorders: a systematic review. J Pediatr 2015; 166:424-31.e6. [PMID: 25449223 DOI: 10.1016/j.jpeds.2014.09.067] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/25/2014] [Accepted: 09/30/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systematically review literature assessing efficacy and safety of pharmacologic treatments in children with abdominal pain-related functional gastrointestinal disorders (AP-FGIDs). STUDY DESIGN MEDLINE and Cochrane Database were searched for systematic reviews and randomized controlled trials investigating efficacy and safety of pharmacologic agents in children aged 4-18 years with AP-FGIDs. Quality of evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation approach. RESULTS We included 6 studies with 275 children (aged 4.5-18 years) evaluating antispasmodic, antidepressant, antireflux, antihistaminic, and laxative agents. Overall quality of evidence was very low. Compared with placebo, some evidence was found for peppermint oil in improving symptoms (OR 3.3 (95% CI 0.9-12.0) and for cyproheptadine in reducing pain frequency (relative risk [RR] 2.43, 95% CI 1.17-5.04) and pain intensity (RR 3.03, 95% CI 1.29-7.11). Compared with placebo, amitriptyline showed 15% improvement in overall quality of life score (P = .007) and famotidine only provides benefit in global symptom improvement (OR 11.0; 95% CI 1.6-75.5; P = .02). Polyethylene glycol with tegaserod significantly decreased pain intensity compared with polyethylene glycol only (RR 3.60, 95% CI 1.54-8.40). No serious adverse effects were reported. No studies were found concerning antidiarrheal agents, antibiotics, pain medication, anti-emetics, or antimigraine agents. CONCLUSIONS Because of the lack of high-quality, placebo-controlled trials of pharmacologic treatment for pediatric AP-FGIDs, there is no evidence to support routine use of any pharmacologic therapy. Peppermint oil, cyproheptadine, and famotidine might be potential interventions, but well-designed randomized controlled trials are needed.
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Affiliation(s)
- Judith J Korterink
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
| | - Juliette M T M Rutten
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
| | - Leonie Venmans
- Pediatric Association of The Netherlands, Utrecht, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
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23
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Sirianni J, Ibrahim M, Patwardhan A. Chronic Pain Syndromes, Mechanisms, and Current Treatments. Molecular and Cell Biology of Pain. Elsevier; 2015. pp. 565-611. [DOI: 10.1016/bs.pmbts.2015.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Affiliation(s)
- M Pasalar
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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25
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Abstract
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.
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Affiliation(s)
- Jose L Barboza
- University of South Florida College of Pharmacy, 12901 Bruce B. Downs Blvd. MDC30, Tampa, FL, 33612, USA.
| | - Nicholas J Talley
- University of Newcastle, Callaghan, NSW, 2308, Australia
- Mayo Clinic, Jacksonville, FL, USA
| | - Baharak Moshiree
- Division of Gastroenterology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
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26
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Ford AC, Moayyedi P, Lacy BE, Lembo AJ, Saito YA, Schiller LR, Soffer EE, Spiegel BMR, Quigley EMM. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014; 109 Suppl 1:S2-26; quiz S27. [PMID: 25091148 DOI: 10.1038/ajg.2014.187] [Citation(s) in RCA: 376] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alexander C Ford
- 1] Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK [2] First author on the monograph, but is not a member of the Task Force
| | - Paul Moayyedi
- 1] Farncombe Family Digestive Health Research Institute, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada [2] Conducted systematic reviews with the support of A.C. Ford, and carried out the technical analyses of the data independent of the Task Force
| | - Brian E Lacy
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Anthony J Lembo
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Lawrence R Schiller
- Baylor University Medical Center, Digestive Health Associates of Texas, Dallas, Texas, USA
| | - Edy E Soffer
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Brennan M R Spiegel
- UCLA School of Medicine, UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, California, USA
| | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
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27
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Bellini M, Gambaccini D, Stasi C, Urbano MT, Marchi S, Usai-Satta P. Irritable bowel syndrome: A disease still searching for pathogenesis, diagnosis and therapy. World J Gastroenterol 2014; 20:8807-8820. [PMID: 25083055 PMCID: PMC4112881 DOI: 10.3748/wjg.v20.i27.8807] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/21/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder in primary and secondary care. It is characterised by abdominal discomfort, pain and changes in bowel habits that can have a serious impact on the patient’s quality of life. The pathophysiology of IBS is not yet completely clear. Genetic, immune, environmental, inflammatory, neurological and psychological factors, in addition to visceral hypersensitivity, can all play an important role, one that most likely involves the complex interactions between the gut and the brain (gut-brain axis). The diagnosis of IBS can only be made on the basis of the symptoms of the Rome III criteria. Because the probability of organic disease in patients fulfilling the IBS criteria is very low, a careful medical history is critical and should pay particular attention to the possible comorbidities. Nevertheless, the severity of the patient’s symptoms or concerns sometimes compels the physician to perform useless and/or expensive diagnostic tests, transforming IBS into a diagnosis of exclusion. The presence of alarming symptoms (fever, weight loss, rectal bleeding, significant changes in blood chemistry), the presence of palpable abdominal masses, any recent onset of symptoms in patient aged over 50 years, the presence of symptoms at night, and a familial history of celiac disease, colorectal cancer and/or inflammatory bowel diseases all warrant investigation. Treatment strategies are based on the nature and severity of the symptoms, the degree of functional impairment of the bowel habits, and the presence of psychosocial disorders. This review examines and discusses the pathophysiological aspects and the diagnostic and therapeutic approaches available for patients with symptoms possibly related to IBS, pointing out controversial issues and the strengths and weaknesses of the current knowledge.
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28
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Lazaraki G, Chatzimavroudis G, Katsinelos P. Recent advances in pharmacological treatment of irritable bowel syndrome. World J Gastroenterol 2014; 20:8867-8885. [PMID: 25083060 PMCID: PMC4112893 DOI: 10.3748/wjg.v20.i27.8867] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 03/13/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a highly prevalent functional disorder that reduces patients’ quality of life. It is a chronic disorder characterized by abdominal pain or discomfort associated with disordered defecation in the absence of identifiable structural or biochemical abnormalities. IBS imposes a significant economic burden to the healthcare system. Alteration in neurohumoral mechanisms and psychological factors, bacterial overgrowth, genetic factors, gut motility, visceral hypersensitivity, and immune system factors are currently believed to influence the pathogenesis of IBS. It is possible that there is an interaction of one or more of these etiologic factors leading to heterogeneous symptoms of IBS. IBS treatment is predicated upon the patient’s most bothersome symptoms. Despite the wide range of medications and the high prevalence of the disease, to date no completely effective remedy is available. This article reviews the literature from January 2008 to July 2013 on the subject of IBS peripherally acting pharmacological treatment. Drugs are categorized according to their administration for IBS-C, IBS-D or abdominal pain predominant IBS.
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Eswaran S, Guentner A, Chey WD. Emerging Pharmacologic Therapies for Constipation-predominant Irritable Bowel Syndrome and Chronic Constipation. J Neurogastroenterol Motil 2014; 20:141-51. [PMID: 24840367 PMCID: PMC4015201 DOI: 10.5056/jnm.2014.20.2.141] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/07/2013] [Accepted: 11/20/2013] [Indexed: 12/15/2022] Open
Abstract
Irritable bowel syndrome with constipation and chronic functional constipation are common digestive disorders that negatively impact quality of life and account for billions of dollars in health care costs. Related to the heterogeneity of pathogenesis that underlie these disorders and the failure of symptoms to reliably predict underlying pathophysiology, traditional therapies provide relief to only a subset of affected individuals. The evidence surrounding new and emerging pharmacologic treatments, which include both luminally and systemically acting drugs, is discussed here. These include agents such as lubiprostone, bile acid modulations, guanylate cyclase-C receptor agonists, serotonin receptor modulators and herbal therapies.
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Affiliation(s)
- Shanti Eswaran
- University of Michigan Health System, Ann Arbor, MI, USA
| | | | - William D Chey
- University of Michigan Health System, Ann Arbor, MI, USA
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Chang FY. Irritable bowel syndrome: The evolution of multi-dimensional looking and multidisciplinary treatments. World J Gastroenterol 2014; 20:2499-2514. [PMID: 24627587 PMCID: PMC3949260 DOI: 10.3748/wjg.v20.i10.2499] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 10/16/2013] [Accepted: 01/02/2014] [Indexed: 02/06/2023] Open
Abstract
Irritable bowel syndrome (IBS) is common in the society. Among the putative pathogeneses, gut dysmotility results in pain and disturbed defecation. The latter is probably caused by the effect of abnormal gut water secretion. The interaction between abnormal gas accumulation, abdominal pain and bloating remains controversial. Visceral hypersensitivity and its modification along with the central transmission are the characteristics of IBS patients. The identification of biologic markers based on genetic polymorphisms is undetermined. Imbalanced gut microbiota may alter epithelial permeability to activate nociceptive sensory pathways which in turn lead to IBS. Certain food constituents may exacerbate bowel symptoms. The impact of adult and childhood abuses on IBS is underestimated. Using the concept of biopsychosocial dysfunction can integrate multidimensional pathogeneses. Antispasmodics plus stool consistency modifiers to treat the major symptoms and defecation are the first-line drug treatment. New drugs targeting receptors governing bowel motility, sensation and secretion can be considered, but clinicians must be aware of their potential serious side effects. Psychiatric drugs and modalities may be the final options for treating intractable subjects. Probiotics of multi-species preparations are safe and worth to be considered for the treatment. Antibiotics are promising but their long-term safety and effectiveness are unknown. Diet therapy including exclusion of certain food constituents is an economic measure. Using relatively safe complementary and alternative medicines (CAMs) may be optional to those patients who failed classical treatment. In conclusion, IBS is a heterogeneous disorder with multidimensional pathogeneses. Personalized medicines with multidisciplinary approaches using different classes of drugs, psychiatric measures, probiotics and antibiotics, dietary therapy, and finally CAMs, can be considered.
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Chapman RW, Stanghellini V, Geraint M, Halphen M. Randomized clinical trial: macrogol/PEG 3350 plus electrolytes for treatment of patients with constipation associated with irritable bowel syndrome. Am J Gastroenterol 2013; 108:1508-15. [PMID: 23835436 DOI: 10.1038/ajg.2013.197] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 06/04/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Polyethylene glycol (PEG) 3350 plus electrolytes (PEG 3350+E) is an established treatment for constipation and has been proposed as a treatment option for constipation associated with irritable bowel syndrome (IBS-C). This study aimed to compare the efficacy and safety of PEG 3350+E vs. placebo in adult patients with IBS-C. METHODS Following a 14-day run-in period without study medication, patients with confirmed IBS-C were randomized to receive PEG 3350+E (N=68) or placebo (N=71) for 28 days. The primary endpoint was the mean number of spontaneous bowel movements (SBMs) per day in the last treatment week. RESULTS In both groups, mean weekly number of SBMs (±s.d.) increased from run-in. The difference between the groups in week 4 (PEG 3350+E, 4.40±2.581; placebo, 3.11±1.937) was statistically significant (95% confidence interval: 1.17, 1.95; P<0.0001). Although mean severity score for abdominal discomfort/pain was significantly reduced compared with run-in with PEG 3350+E, there was no difference vs. placebo. Spontaneous complete bowel movements, responder rates, stool consistency, and severity of straining also showed superior improvement in the PEG 3350+E group over placebo in week 4. The most common drug related treatment-emergent adverse events were abdominal pain (PEG 3350+E, 4.5%; placebo, 0%) and diarrhoea (PEG 3350+E, 4.5%; placebo, 4.3%). CONCLUSIONS In IBS-C, PEG 3350+E was superior to placebo for relief of constipation, and although a statistically significant improvement in abdominal discomfort/pain was observed compared with baseline, there was no associated improvement compared with placebo. PEG 3350+E is a well-established and effective treatment that should be considered suitable for use in IBS-C.
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Abstract
Irritable bowel syndrome (IBS), characterized by abdominal pain or discomfort associated with a change in bowel patterns, is one of the most common functional gastrointestinal disorders. Because no single drug effectively relieves all IBS symptoms, management relies on dietary and lifestyle modifications, as well as pharmacologic and nonpharmacologic therapies. The authors review current approaches to treatment and discuss nursing implications.
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Layer P. Management of irritable bowel syndrome with constipation: a flexible approach to treating a complex condition with multiple symptoms. Expert Rev Gastroenterol Hepatol 2013; 7:9-14. [PMID: 23859755 DOI: 10.1586/17474124.2013.820049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Irritable bowel syndrome is a heterogeneous disease with a complex underlying pathophysiology and multiple symptoms - that is, clinical manifestation patterns. As such, management of irritable bowel syndrome requires a flexible approach tailored to the individual patient. This article reviews rational, evidence-based management strategy and treatment options for this variable condition.
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Affiliation(s)
- Peter Layer
- Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Orchideenstieg 14, 22297 Hamburg, Germany.
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34
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Abstract
OBJECTIVES The aims were: firstly, to review the definition and diagnosis of irritable bowel syndrome with constipation (IBS-C, a subtype of IBS); secondly, to critically assess current therapies for IBS-C with a focus on effectiveness for abdominal pain; and thirdly, to review clinical studies evaluating the efficacy of linaclotide, a therapy recently approved by the US Food and Drug Administration for the treatment of adults with IBS-C and chronic idiopathic constipation and the European Medicines Agency for the symptomatic treatment of moderate to severe IBS-C in adults, and in development for treatment of IBS-C worldwide. METHODS A comprehensive literature review was performed to summarize IBS-C and current treatments. MEDLINE and gastrointestinal society congress proceedings were searched to identify data from linaclotide clinical studies in adults with IBS-C published between January 2010 and August 2012. RESULTS IBS-C patients have chronic, relapsing symptoms. Rome III diagnostic criteria define the presence of chronic abdominal pain that improves with defecation and has onset associated with changes in stool frequency or form as a key element of IBS-C and other IBS subtypes. IBS-C patients generally are not completely satisfied with existing therapies. A therapy that treats bowel and abdominal symptoms effectively and can be taken safely on a chronic basis is a current unmet need for IBS-C patients. The guanylate cyclase-C agonist linaclotide has been shown to reduce visceral hypersensitivity in preclinical studies and to improve abdominal pain and constipation symptoms in phase 2 and 3 clinical trials of IBS-C patients. CONCLUSIONS IBS-C is a functional gastrointestinal disorder with chronic, relapsing abdominal and constipation symptoms. By virtue of its effects in relieving abdominal pain by reducing visceral hypersensitivity and improving constipation symptoms by increasing intestinal secretion and accelerating transit, linaclotide may be uniquely positioned for a role in the management of IBS-C patients.
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Abstract
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.
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Affiliation(s)
- J Fortea
- Laboratories Almirall S.A., Barcelona, Spain.
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36
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Abstract
The functional gastrointestinal disorders are common disorders that are associated with significant quality-of-life impairment and considerable economic burden on the healthcare system. They are frequently associated with a comorbid psychiatric condition; this, together with a striking lack of effective pharmacological therapies, means they represent a considerable therapeutic challenge to the treating physician. In this overview, we examine the evidence to support the use of agents currently used in the management of the more common functional gastrointestinal disorders and review emerging therapies.
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Affiliation(s)
- Orla F Craig
- Alimentary Pharmabiotic Centre, University College Cork, Cork, Ireland and Department of Medicine, Clinical Sciences Building, Cork University Hospital, Cork, Ireland
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Andresen V, Keller J, Pehl C, Schemann M, Preiss J, Layer P. Irritable bowel syndrome--the main recommendations. Dtsch Arztebl Int 2011; 108:751-60. [PMID: 22163251 DOI: 10.3238/arztebl.2011.0751] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 08/01/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome is characterized by chronic abdominal symptoms and irregular bowel movements without any cause than can be revealed by routine diagnostic assessment. In recent years, its pathophysiology has come to be much better understood, and new therapeutic approaches have been developed. These advances were taken into consideration and assessed for their relevance to clinical practice in the framework of a new interdisciplinary S3 guideline. METHODS A systematic search of the literature retrieved a total 5573 articles, from which 243 were selected on the basis of criteria relating to their form and content, individually assessed, and summarized in evidence tables. The recommendations formulated in this way were discussed in a Delphi procedure and a consensus conference, then accordingly modified and finalized. RESULTS Variable symptom constellations are caused by disturbances of gastrointestinal regulation at multiple levels. The diagnosis of irritable bowel syndrome requires both chronic bowel symptoms that interfere with everyday life and the exclusion of relevant differential diagnoses. Its treatment is based on general therapeutic principles, dietary recommendations, psychological components, and symptomatic medication. Bulking agents, laxatives, spasmolytics, loperamide, and probiotic agents are recommended (with variable recommendation strengths), as are--for selected patients--antidepressants, 5-HT4 agonists, 5-HT3 antagonists, and topical antibiotics. CONCLUSION The first German S3 guideline on irritable bowel syndrome translates up-to-date scientific knowledge as represented in current publications into concrete recommendations for diagnosis and treatment in clinical practice. In the future, it is likely that further causative pathophysiological mechanisms will be discovered; this should lead, in turn, to the development of new, causally directed treatments, which will supplement or replace the traditional, purely symptomatic treatments that are still in use today.
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Affiliation(s)
- Viola Andresen
- Israelitisches Krankenhaus Medizinische Klinik, Hamburg, Germany.
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38
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Chey WD, Maneerattaporn M, Saad R. Pharmacologic and complementary and alternative medicine therapies for irritable bowel syndrome. Gut Liver 2011; 5:253-66. [PMID: 21927652 PMCID: PMC3166664 DOI: 10.5009/gnl.2011.5.3.253] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 06/25/2011] [Indexed: 12/11/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by episodic abdominal pain or discomfort in association with altered bowel habits (diarrhea and/or constipation). Other gastrointestinal symptoms, such as bloating and flatulence, are also common. A variety of factors are believed to play a role in the development of IBS symptoms, including altered bowel motility, visceral hypersensitivity, psychosocial stressors, altered brain-gut interactions, immune activation/low grade inflammation, alterations in the gut microbiome, and genetic factors. In the absence of biomarkers that can distinguish between IBS subgroups on the basis of pathophysiology, treatment of this condition is predicated upon a patient's most bothersome symptoms. In clinical trials, effective therapies have only offered a therapeutic gain over placebos of 7-15%. Evidence based therapies for the global symptoms of constipation predominant IBS (IBS-C) include lubiprostone and tegaserod; evidence based therapies for the global symptoms of diarrhea predominant IBS (IBS-D) include the probiotic Bifidobacter infantis, the nonabsorbable antibiotic rifaximin, and alosetron. Additionally, there is persuasive evidence to suggest that selected antispasmodics and antidepressants are of benefit for the treatment of abdominal pain in IBS patients. Finally, several emerging therapies with novel mechanisms of action are in development. Complementary and alternative medicine therapies including probiotics, herbal therapies and acupuncture are gaining popularity among IBS sufferers, although concerns regarding manufacturing standards and the paucity of high quality efficacy and safety data remain.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
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Kwon JG, Park KS, Park JH, Park JM, Park CH, Lee KJ, Park HJ, Rhee JC. [Guidelines for the treatment of irritable bowel syndrome]. Korean J Gastroenterol 2011; 57:82-99. [PMID: 21350320 DOI: 10.4166/kjg.2011.57.2.82] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Joong Goo Kwon
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Korea
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40
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Abstract
The aim of this article is to review the pathophysiology and clinical role of serotonin receptor modulators used in the treatment of irritable bowel syndrome. Serotonin is an important monoamine neurotransmitter that plays a key role in the initiation of peristaltic and secretory refl exes, and in modulation of visceral sensations. Several serotonin receptor subtypes have been characterized, of which 5HT3, 5HT4, and 5HT1b are the most important for GI function. 5HT4 agonists (eg, tegaserod) potentiate peristalsis initiated by 5HT1 receptor stimulation. 5HT4 agonists are therefore useful in constipation predominant form of IBS and in chronic constipation. 5HT3 antagonists (Alosetron and Cilansetron) prevent the activation of 5HT3 receptors on extrinsic afferent neurons and can decrease the visceral pain associated with IBS. These agents also retard small intestinal and colonic transit, and are therefore useful in diarrhea-predominant IBS. Tegaserod has been demonstrated in several randomized, placebo controlled trials to relieve global IBS symptoms as well as individual symptoms of abdominal discomfort, number of bowel movements and stool consistency. Several randomized, controlled trials have shown that alosetron relieves pain, improves bowel function, and provides global symptom improvement in women with diarrhea-predominant irritable bowel syndrome. However, ischemic colitis and severe complications of constipation have been major concerns leading to voluntary withdrawal of Alosetron from the market followed by remarketing with a comprehensive risk management program.
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Affiliation(s)
- Mohammad Fayyaz
- Division of Gastroenterology, Department of Medicine, University at Buffalo School of Medicine SUNY, Buffalo, NY, USA
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41
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Abstract
OBJECTIVE To explore the clinical dimensions of chronic constipation and the role played in its treatment by laxatives in general and by polyethylene glycol 3350 (MiraLAX * ) in particular. * MiraLAX is a registered trade name of Schering-Plough HealthCare Products, Inc., Memphis, TN, USA, a subsidiary of Merck & Co., Inc. RESEARCH DESIGN AND METHODS Published reports of clinical trials involving polyethylene glycol 3350, together with published articles examining the epidemiology, demographics, etiology, evaluation, and management of chronic constipation, were identified in a literature search through November 2009 using PubMed. Congress proceedings and guideline databases of leading national and international gastroenterology associations were also explored for relevant recommendations and evaluations. MAIN OUTCOME MEASURES Constipation, often defined differently by patients and physicians, is typically associated with excessive straining, hard stools, infrequent bowel movements, and sensations of incomplete evacuation. Specific criteria are available to aid physicians in making a diagnosis of functional constipation. Initial patient management typically involves dietary and lifestyle changes, although this approach is supported by limited clinical evidence and is often a source of considerable patient frustration. A laxative is needed when these changes do not sufficiently relieve constipation. Multiple agents from several different laxative classes are available, differing in mechanism of action, safety and efficacy profile, and clinical evidence supporting their use. RESULTS Twenty-one studies involving a total of 1949 patients were included in the overall review of polyethylene glycol 3350. Fifteen studies used randomized designs, eight were comparative trials, seven were conducted in pediatric populations, and three had elderly components. LIMITATIONS Limitations of this review included lack of comparability among the various patient populations described; focus on a single agent; potential publication bias; non-systematic review. CONCLUSIONS Polyethylene glycol 3350, an osmotic laxative available over the counter, has been shown to be safe and effective in treating chronic constipation in children and adults, including the elderly, across multiple clinical trials, with a safety profile comparable to that of placebo. Polyethylene glycol 3350 received a grade A recommendation for improving stool frequency and consistency from the American College of Gastroenterology Task Force on Chronic Constipation.
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42
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Abstract
Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are both associated with recurrent abdominal pain and are among the most commonly diagnosed medical problems in pediatrics. The majority of patients with mild complaints improve with reassurance and time. For a distinct subset of patients with more severe and disabling illness, finding effective treatment for these disorders remains a challenge. Based on the biopsychosocial model of functional disease, the Rome III criteria have helped frame FAP and IBS in terms of being a positive diagnosis and not a diagnosis of exclusion. However, the lack of a single, proven intervention highlights the complex interplay of pathologic mechanisms likely involved in the development of childhood FAP and IBS and the need for a multidisciplinary, integrated approach. This article discusses the epidemiology, proposed mechanisms, clinical approach and therapeutic options for the management of FAP and IBS in children and adolescents.
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Affiliation(s)
- Eric Chiou
- Center for Motility & Functional Gastrointestinal Disorders, Children’s, Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA
| | - Samuel Nurko
- Center for Motility & Functional Gastrointestinal Disorders, Children’s, Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA
- Author for correspondence: Tel.: +1 617 355 6055,
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43
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Abstract
Gut-acting therapies are common therapies for irritable bowel syndrome (IBS). Most of these peripheral acting agents are primarily targeted at individual symptoms. The evidence supporting the use of these agents in IBS is largely anecdotal. Serotonergic agents and the chloride channel activator lubiprostone have shown efficacy in treating symptoms of IBS. The clinical evidence supporting the use of these agents is based on data from high-quality clinical trials. The use of serotonergic agents for IBS in the United States is limited to the 5-hydroxytryptamine-3 antagonist alosetron in the treatment of women with severe IBS with diarrhea refractory to traditional therapy.
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Affiliation(s)
- Richard J Saad
- Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA.
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Lunsford TN, Harris LA. Lubiprostone: evaluation of the newest medication for the treatment of adult women with constipation-predominant irritable bowel syndrome. Int J Womens Health 2010; 2:361-74. [PMID: 21151683 PMCID: PMC2990905 DOI: 10.2147/ijwh.s4537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a chronic disorder that affects primarily female patients and is thought also to afflict approximately 7%-10% of the population of the Western World. Although bowel habits may change over the course of years, patients with IBS are characterized according to their predominant bowel habit, constipation (IBS-C), diarrhea (IBS-D), or mixed type (IBS-M), and treatments are focused toward the predominant symptom. Current treatments for IBS-C have included fiber, antispasmodics, osmotic and stimulant laxatives, and the now severely limited 5-HT(4) agonist tegaserod. No one agent has been universally successful in the treatment of this bothersome syndrome and the search for new agents continues. Lubiprostone (Amitiza(®)), a novel compound, is a member of a new class of agents called prostones and was approved for the treatment of chronic idiopathic constipation in 2006 at a dose of 24 μg twice daily and then in 2008 for the treatment of IBS-C in women only at a dose of 8 μg twice daily. Its purported mechanism is as a type 2 chloride channel activator, but recent evidence suggests that it may also work at the cystic fibrosis transport receptor. This article will compare the newly proposed mechanism of action of this compound to the purported mechanism and review the structure, pharmacology, safety, efficacy, and tolerability of this new therapeutic option. Clinical trial data leading to the approval of this agent for the treatment of IBS-C and the gender-based understanding of IBS, as well as this agent's place among existing and emerging therapies, will be examined.
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Affiliation(s)
- Tisha N Lunsford
- Department of Gastroenterology and Hepatology, Mayo Clinic – School of Medicine, Scottsdale, Arizona, USA
| | - Lucinda A Harris
- Department of Gastroenterology and Hepatology, Mayo Clinic – School of Medicine, Scottsdale, Arizona, USA
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45
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Abstract
IBS is a common gastrointestinal condition characterized by chronic or recurrent abdominal pain associated with altered bowel habits. IBS is considered a functional bowel disorder (that is, not defined by structural or biochemical abnormalities) and is diagnosed using symptom-based criteria. Limited and judicious use of diagnostic testing is recommended, particularly in patients with typical symptoms of IBS without alarm signs and symptoms. Management of IBS is based on a multifactorial approach and includes establishment of an effective patient-provider relationship, education, reassurance, dietary alterations, pharmacotherapy, behavioral and psychological treatment. Patient-centered care is recommended, in which management is focused on the patient's most bothersome and impactful symptoms, their preferences and previous experiences with treatment, and addressing factors associated with the onset and exacerbation of symptoms. Pharmacotherapy is typically targeted against the predominant symptom. This Review discusses the current evidence-based recommendations for the diagnosis and management of IBS. An improved understanding of the recommended diagnostic and therapeutic approaches for IBS will lead to greater patient satisfaction, as well as reduced health-care costs.
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Affiliation(s)
- Sarah Khan
- Center for Neurobiology of Stress, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CHS 47-122, Los Angeles, CA 90095-7378, USA
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46
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Abstract
Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are among the most commonly diagnosed medical problems in pediatrics. Symptom-based Rome III criteria for FAP and IBS have been validated and help the clinician in making a positive diagnosis. The majority of patients with mild complaints improve with reassurance and time. For a distinct subset of patients with more severe and disabling illness, finding effective treatment for these disorders remains a challenge. Over the years, a wide range of therapies have been proposed and studied. The lack of a single, proven intervention highlights the complex interplay of biopsychosocial factors probably involved in the development of childhood FAP and IBS, and the need for a multidisciplinary, integrated approach. This article reviews the current literature on the efficacy of pharmacologic, dietary and psychosocial interventions for FAP and IBS in children and adolescents.
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Affiliation(s)
- Eric Chiou
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02155, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02155, USA
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47
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Abstract
Irritable bowel syndrome (IBS) is a highly prevalent functional bowel disorder routinely encountered by healthcare providers. Although not life-threatening, this chronic disorder reduces patients' quality of life and imposes a significant economic burden to the healthcare system. IBS is no longer considered a diagnosis of exclusion that can only be made after performing a battery of expensive diagnostic tests. Rather, IBS should be confidently diagnosed in the clinic at the time of the first visit using the Rome III criteria and a careful history and physical examination. Treatment options for IBS have increased in number in the past decade and clinicians should not be limited to using only fiber supplements and smooth muscle relaxants. Although all patients with IBS have symptoms of abdominal pain and disordered defecation, treatment needs to be individualized and should focus on the predominant symptom. This paper will review therapeutic options for the treatment of IBS using a tailored approach based on the predominant symptom. Abdominal pain, bloating, constipation and diarrhea are the four main symptoms that can be addressed using a combination of dietary interventions and medications. Treatment options include probiotics, antibiotics, tricyclic antidepressants, selective serotonin reuptake inhibitors and agents that modulate chloride channels and serotonin. Each class of agent will be reviewed using the latest data from the literature.
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Affiliation(s)
- Brian E Lacy
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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48
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Abstract
Therapy of pediatric functional gastrointestinal disorders is best done within the context of a multidisciplinary biopsychosocial approach. Pharmacotherapy is often sought by patients and families who hope to find a "pill" that will lead to rapid symptom relief. Yet, there is only scant published evidence for the efficacy of a variety of medical interventions in childhood functional abdominal pain and irritable bowel syndrome. This article reviews the pediatric studies that have addressed pharmacotherapy in children with pain predominant functional gastrointestinal disorders.
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Drossman DA, Chey WD, Johanson JF, Fass R, Scott C, Panas R, Ueno R. Clinical trial: lubiprostone in patients with constipation-associated irritable bowel syndrome--results of two randomized, placebo-controlled studies. Aliment Pharmacol Ther 2009; 29:329-41. [PMID: 19006537 DOI: 10.1111/j.1365-2036.2008.03881.x] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Effective treatments for irritable bowel syndrome with constipation (IBS-C) are lacking. AIM To assess the efficacy and safety of lubiprostone in IBS-C. METHODS A combined analysis was performed among 1171 patients with a Rome II diagnosis of IBS-C in two phase-3 randomized trials of lubiprostone 8 mcg vs. placebo twice daily for 12 weeks. Using a balanced seven-point Likert scale ranging from significantly relieved (+3), to significantly worse (-3), patients responded on their electronic diary to the question: 'How would you rate your relief of IBS symptoms over the past week compared to how you felt before you entered the study?'. The primary efficacy endpoint was the percentage of overall responders. RESULTS Using an intent-to-treat analysis with last observation carried forward, a significantly higher percentage of lubiprostone-treated patients were considered overall responders compared with those treated with placebo (17.9% vs. 10.1%, P=0.001). Patients treated with lubiprostone reported a similar incidence of adverse events to those treated with placebo. CONCLUSIONS The percentage of overall responders based on patient-rated assessments of IBS-C symptoms was significantly improved in patients treated with lubiprostone 8 mcg twice daily compared to those treated with placebo. Lubiprostone was well tolerated with a favourable safety profile.
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Affiliation(s)
- D A Drossman
- University of North Carolina Center for Functional Gl and Mobility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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50
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Brandt LJ, Chey WD, Foxx-orenstein AE, Quigley EM, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Moayyedi P. An Evidence-Based Systematic Review on the Management of Irritable Bowel Syndrome: . Am J Gastroenterol 2009; 104:S8-S35. [DOI: 10.14309/00000434-200901001-00002] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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