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New Perspective in Irritable Bowel Syndrome
Anthony Lembo, M.D.Professor of Medicine
Harvard Medical School
Director, GI Motility and FBD Center
Beth Israel Deaconess Medical Center
Boston, MA
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Early description of Symptoms Defining IBS
• IBS: Chronic abdominal pain associated with altered bowel habits (diarrhea/constipation/mixed)
• Symptoms are not new
• “The bowels are at one time constipated, at another lax, in the same person.
How the disease has two such different symptoms I do not profess to explain. . . .” W Cumming, 1849
•Historical terms– mucous colitis – colonic spasm – neurogenic mucous colitis – irritable colon
W. Cumming, London Medical Gazette, 1849;NS9;969-973.
– unstable colon– nervous colon– nervous colitis– spastic colitis
•
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E3
IBS Prevalence According To Age, Geography and Sex
0 10 20 30 40 50 60 70 800
10
20
30
Age (years)
Hungin APS et al. APT 2005; 21:1365
Hungin APS et al. APT 2003; 17:643
Kumano H et al. AJG 2004; 99:370
Lau EMC et al. Dig Dis Sci 2002; 47:621
%
Rome
IBS W. Europe
USA
Japan
China
1.2-2 x Women : Men
(particularly IBS-C)
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Prevalence IBS in Japan
• Rome II: 6.1% - 14.2% (4.5% - 12.9% men;
7.8% - 15.5.% women) • Kamazawa et al. 2004, Kumano et al. 2004
• Rome III: 13.1%
• 15.5% women; 10.7% men
• IBS-D 29%, IBS-C 24%, IBS-M 47%
• Miwa et al. 2008
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~25%
Consulters
~75%
Nonconsulters
Pain/Severity
Concern for
malignancy/IBD
Psychological
disturbance
Consulters vs. Non-consulters
IBS Non-consulters and Healthy Controls have Similar Psychosocial Profiles
IBS patients have higher rates of psychosocial abnormalities
(anxiety/depression)
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Most Bothersome Symptoms of IBS
Ballou S. t al. Clin Gastroenterol Hepatol. 2019 Aug 13. [Epub ahead of print]
Impact of Symptoms
Data from IBS in America Survey n=1885
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Lacy B et al. Gastroenterology. 2016;150:1393-1407 Rome Organization. Rome IV Disorders and Criteria.
Rome IV Criteria for IBS
*Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
Associated
with a change
in frequency of stool
Associated
with a change in
form/appearance
of stool
Recurrent abdominal pain
at least 1 day / week in the last 3 months
associated with 2 or more of the following:
Related to
defecationCOPYRIGHT
IBS Subtypes Based on Stool ConsistencyBased on Days With Abnormal BMs
Type 1
Separate hard lumps, like nuts (hard to pass)
Type 2
Sausage-shaped but lumpy
IBS-ConstipationHard/lumpy stools ≥25%
Loose/watery stools <25%
Type 3
Like a sausage but with cracks on its surface
Type 4
Like a sausage or snake, smooth and soft
Type 5
Soft blobs with clear-cut edges (passed easily)
IBS-MixedHard/lumpy stools ≥25%
Loose/watery stools ≥25%
Type 6
Fluffy pieces with ragged edges; a mushy stool
Type 7
Watery, no solid pieces; entirely liquid
IBS-DiarrheaHard/lumpy stools <25%
Loose/watery stools ≥25%
Lacy BE et al, Bowel Disorders, 1393-1407.e5, r.
Bristol Stool Form Scale1,2
8
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E9Turn Down the Pain Volume. The Rheumatologist October 2009 • Daniel J. Clauw,
IBS Overlaps with other Common Chronic Pain Conditions
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19701960 1980 1990 2000 2010 20141950 2019
MotilityMyoelectrical Marker
Brain-Gut Interactions
Visceral Hypersensitivity
Mechanisms
Inflammation
Microflora
Food and Diet
Mucosal Immune Dysfunction
Stress affects GI function
Meals
Pain/Motility
Pain sensitivity
3 cpm
motility
Clusteredcontractions
CNS/ENSAutonomic reactivity
Visceralhypersensitivity
Postinfection
IBS
CNSBrain Imaging
Probiotics
Food and Diet
FODMAP
Gluten
Neuroplasticity and Neurogenetics
Biomarkers
EpigenomicsRome Criteria
IBS - Physiologic Research
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What Causes IBS Symptoms?
Genes
Early learning
Family influences
Susceptible
individual
External stressors
IBS symptoms
Psychological
disturbance
Physiological
disturbance
• Stressful adverse life events
• Chronic psychological stress
• Gastrointestinal infection
• Alterations in gut microbiota
• Changes in diet
Courtesy of Robin Spiller
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IBS is Common After an Infectious GastroenteritisPost-infectious IBS (PI-IBS)
• IBS is present in 10% of individuals
12 months after an infection
• Parasitic > Bacterial > Viral
• Risk of IBS > in women, antibiotic
use, anxiety, depression,
somatiziation neuroticism
• Gastroenteritis affects 15% of US
population /year
• Post-infectious IBS is the leading
cause of IBSMarshall et al. Gut 2010 May;59(5):605-11.
Flem et al.. Gastroenterology. 2017 April ; 152(5): 1042–1054
PI-IBS Walkerton, Ontario
10 year f/u
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Post-Infectious IBS is Associated with Increased Immune Cells and Hypersensitivity
0
50
100
150
200
Discomf Inflamm Psych
IBS + IBS - Control
*
* *
Gwee, Gut, 1999;44:400.
Control
Post infectious IBS
Spiller, Gut, 2000; 47(6): 807.
Increased
Enterochromaffin Cells
Visceral Hypersensitivity
Chronic lymphocytes at f/u
Intestinal permeability
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Evidence for Increased Intestinal Permeability in IBS (i.e., Leaky Gut)
• 1st described in IBS in 2000 (post-infectious) (Spiller et al)
• Has since been demonstrated in all subtypes of IBS
• Fecal supernatant from IBS patients increases colonic permeability in mice
• Permeability decreases with GFD and low-FODMAP diet
• Glutamine 5 g tid x 8 wks improved IBS symptoms and permeability (Zhou et al. Gut 2018)
Singh P, et al. United European Gastroenterology Journal 2019, Vol. 7(5) 709–715
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Proposed Mechanism of Post-infectious IBS
E15IBSSmart.com
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Anti-CdtB and vinculin antibodies are common in IBS-D
Potential Biomarker for Post-infectious IBS-DAnti-CdtB and anti-vinculin antibodies are elevated in IBS-D compared with IBD, UC,
and celiac disease
E16Pimentel et al. PLOS One 2015
Morales W, et al. Digestive Diseases and Sciences. Published on-line May 2019
IBS-D IBS-D
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Diagnosing IBS in the ClinicHistory and Physical Exam
• History
• Typical Symptoms (Rome)
• Timeline and triggers
• Alarm features• FH IBD/Colon Ca/celiac; weight loss; anemia, blood in
stools, nocturnal awakening, onset > 50 yr age
• Travel to areas with high prevalence of infectious
diarrhea, immunosuppression
• Other functional disorders
• Diet
• Medications (including OTC)
• Psychosocial factors (stress,
anxiety, etc.)
• Physical Exam
• Signs of systemic and
local diseases
• Digital rectal exam to
assess for dyssynergia
(especially in patients with
constipation)
Lembo and Camilleri, Chronic Constipation, N Engl J Med 2003;349:1360-1368
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• CRP or fecal calprotectin
• IgA TtG ± quantitative IgA
• Stool diary
• Consider abdominal plain film to
assess for fecal loading
If severe or medically refractory,
refer to specialist for
physiologic testing
Diagnostic Testing for Patients with Suspected IBS
*1. Chey WD, et al. JAMA. 2015;313(9):949-958.
• Strong Recommendation
• Test for giardia
• IgA TtG ± quantitative IgA
• Conditional Recommendation to use
• fecal calprotectin or lactoferrin
• Test for bile acid (serum C4)
• Conditional recommendation against
• Stool for O&P in absence of relevant
travel
• ESR or CRP (except if stool tests are
not available
IBS-D2 IBS-M1 IBS-C1
CBC
Age-appropriate CRC screening
2. Gastroenterology 2019 Sept. 157(3): 851
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Diagnostic Testing for Patients with Suspected IBS
• When to consider a colonoscopy?
• Alarm features
• Age appropriate screening
• Persistent frequent watery diarrhea
• Obtain bx to r/o microscopic colitis
• Failure to respond to therapy
• Breath Testing?
• Insufficient data to recommend
• May predict response to rifaximin• 60% response if positive BT vs. 26% negative BT
Rezaie, Ali MD, MSc American Journal of Gastroenterology 112:S227 (abstract), October 2017
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0
10
20
30
40
50
60
0 2 4 6 8 10 12 14 16
Placebo in Clinical Trials
Week
%
with relief“Placebo” arm
Treatment period Follow-up period
Drug arm
Therapeutic gain
Natural history of disease
Spontaneousremission,Regression tothemean+
“Placebo Effect”
“HawthorneEffect”,Co-interventions,expectation,
reportbias,measurements
Patient-practitionereffect
Key Assumption: Placebo + Treatment Effects are Additive
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•Elsenbruch and Enck. Nature Reviews Gastroenterology &Hepatology 2015
.
Factors Associated with Response to Placebo in IBS trials
• Number of office visits
• Frequency of interventions (i.e., pills)
• Greater pain variability during baseline and
higher pain rating during baselineBallou S et al. Clinical Gastroenterology and Hepatology 2018 16, 1738-1744
• Age and sex are not predictors
• ? Duration of study/run-in, location of study
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•6weeks
•PatientswithIBSwererandomizedto:•Augmented clinician patientrelationship+sham
acupuncture
•Limited clinician patientrelationship +shamacupuncture
•Waitlist
•AugmentedclinicianpatientRelationship
included:
•Warm,empathetic,andconfident
•Activelistening
•20secofthoughtfulsilence
•Physicalcontact– feltpulse
•Increasedtime(30minover3weeks)
Components of the Placebo Effect:A RCT in Patients with IBS
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Hall,Lemboetal. PLoS ONE 7(10): 2012
More dopamine
epinephrine,
norepinephrine)
SAH
COMT
Dopamine
Nor-
epinephrine
Epinephrine
Catechol
estrogen
SAM
COMTmetabolizescatecholamines
Less dopamine
epinephrine,
norepinephrine
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A
3
4
5
6
No Treatment Open Placebo
Glo
bal I
mpr
ovem
ent (
IBS-
GIS
)
B
0
20
40
60
80
100
120
No Treatment Open Placebo
Sym
ptom
Sev
erity
Cha
nge (
IBS-
SSS)
C
0
10
20
30
40
50
60
70
80
No Treatment Open Placebo
Perc
ent w
ith A
dequ
ate R
elief
(IBS
-AR
)
D
0
5
10
15
No Treatment Open Placebo
Qua
lity
of L
ife C
hang
e (IB
S-Q
OL)
p=.002 p=.03
p=.03 p=.08
Open-labelPlacebo(n=43)
NoTreatment(n=37)
Kaptchuk et al. PLOS ONE 5(12): Dec 2010
Adequate Relief
IBS-SSSGlobal Improvement
IBS-QOLCOPYRIGHT
Graded Treatment Response
• Diet, lifestyle advice• Positive diagnosis
• Explain, reassure
• Psychological treatments• Continuing care
• Central neuromodulators
Severe
Moderate
Mild
+
+
• Follow-up visit• Manage stress
• Gut pharmacotherapy
Rome IV Functional Gastrointestinal Disorders. 4th ed. Raleigh, NC: The Rome Foundation; 2016.
A Therapeutic Clinician-patient Relationship is the Cornerstone of Treatment
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Factors Associated with Normal Bowel HabitsData from US General Population (NHANES)
E27Mitsuhashi et al American Journal of Gastroenterology. 113(1):115–123, JANUARY 2018.
95% US population
has between 3 BM/day and 3 BM/wk
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General Dietary and Lifestyle Considerations
• ‘Moderate-to-vigorous’ exercise at least activity 3-5 x /week
• Fluid Intake
• Fiber
• Adequate sleep
• Diet
1. Böhn L1,, Gastroenterology. 2015Nov;149(6):1399-1407.e2.2. Ballou S DigDisSci. 2018Nov;63(11):2983-2991.
“Traditional IBS diet”Eat 3 meals and <3 snacks a day: do not over eat!
Reduce fatty or spicy foods, coffee, alcohol, onions, cabbage and beans
Avoid soft drinks, chewing gum, sweeteners that ends in –ol
Consider increasing soluble fibers - take evenly during the day
Low-FODMAPFermentable oligo-di-mono saccharides and Polyols
? Gluten Free, Paleo, Elemental, South Beach ???
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Fiber
• Lowers risk of CV disease and diabetes, and all-cause mortality
• Important characteristics:
• Solubility, fermentability, viscosity, gel formation
• Food is the best source of fiber!
• whole-grain products, fruit, vegetables, beans, peas/legumes, and nuts /seeds
• ‘Good source of fiber’: > 2.5 grams per serving , ‘High fiber’: >5 grams per serving
• Recommended amounts: 25 g/d women, 38 g/d men
• Psyllium is the most studied fiber supplement in IBS
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Proportion of Patients with Adequate Relief of Symptoms*
Psyllium 10 g per day Improves IBS SymptomsP
ati
en
ts, %
RR-1.66
(95% CI: 1.19-2.3)
Placebo (n=93) B Bran 10 g (n=97) Psyllium 10 g (n=85)
Month 1 Month 2 Month 3
RR-1.44
(95% CI: 1.04-2.0)
Early dropout more common in the bran group. Bijkerk CJ et al. BMJ. 2009;339:b3154.
N=275 IBS patients followed in Primary Care
10 g per day
10 g per day
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Fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs)
Excess
FructoseLactose Fructans Galactans Polyols
fruit
apple, mango, pear,
cherries,
watermelon
sweeteners
sugar, high-fructose
corn syrup
other
honey, asparagus
milk
milk from cows,
goats, or sheep;
custard, ice cream,
yogurt
cheeses
soft unripened
cheeses
(eg, cottage
cheese,
ricotta)
vegetables
onion, leek, garlic,
shallots, artichokes,
asparagus, peas,
beetroot, chicory
cereals
wheat, barley, rye
legumes
baked beans,
chickpeas, kidney
beans, lentils
fruit
apple, pear, apricot,
cherries, peaches,
nectarines, plums,
watermelon
vegetables
cauliflower,
mushrooms
sweeteners
sorbitol, mannitol,
xylitol, chewing gum
1. Shepherd SJ, et al. Am J Gastroenterol. 2013;108:707-717.
2. Shepherd SJ, Gibson PR. J Am Diet Assoc. 2006;106:1631-1639. 3. Barrett JS, Gibson PR. Ther Adv Gastroenterol. 2012;5:261-268.
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Low-FODMAP Diet
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Efficacy of Low-FODMAP Diet in IBS
Halmos EP, et al. Gastroenterology. 2014;146:67-75.
VA
S (
0-1
00
mm
)
Day
Typical Australian diet
Low-FODMAP diet
60
40
20
P<.001
Böhn L, et al. Gastroenterology. 2015. doi: 10.1053/j.gastro.2015.07.054.
Low-FODMAP vs.
Typical Australian Diet
Low-FODMAP vs.
“Traditional IBS Diet”
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Fructans and Not Gluten Induces Symptoms in Non-celiac Gluten Sensitivity and IBS
Murray et al. Am J Gastroenterol 2014 Jan;109(1):110-9
Common fructans
Wheat including bread, pasta, etc.,
onions,, garlic, barley, brussels sprouts,
cabbage, broccoli,, artichoke, inulin
Skodje et al. Gastroenterology 2018;154:529–539
Fructan distends the colon with gas
Fructose distends the small bowel with waterCOPYRIGHT
Frischer-Ravens et al. Gastroenterology 2019;157:109–118
Confocal Light Endoscopy (CLE) positive rates: wheat (60%), yeast(20%),
milk(9%), soy(6%), egg(4%)
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Severe
Moderate
Mild
+
+
● Psychological treatments
● Continuing care
● Improve functioning
● Follow-up visit
● Manage stress
● Pharmacotherapy
● Diet, lifestyle, advice
● Positive diagnosis
● Explain, reassure
Graded Treatment of IBS
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Many Treatments Options for IBS
Bloating/ distension
Altered bowel
function
Abdominal pain
PEG, polyethylene glycol; SNRI, serotonin and norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant
DiarrheaAntispasmodics
Loperamide
TCA
Rifaximin**
Eluxadoline**
Alosetron**
Ondansetron
Bile Acid Binder
ConstipationPsyllium
Osmotic laxatives (PEG)
Lubiprostone*
Linaclotide*
Plecanatide*
Biofeedback (dyssynergia)
Diet (eg, FODMAP)
Probiotics
Rifaximin**
Antispasmodics
SNRI/TCA
Rifaximin**
Eluxadoline **
Alosetron**
Lubiprostone*
Linaclotide*
Plecanatide*
FDA approved for IBS-C* /IBS-D**
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First Line Treatment for IBS
• Constipation
• Fiber (soluble): 5 g QD – increase if tolerated to 10 g
• Polyethylene glycol: 17 g QD, titrate until stools are soft but formed
• Diarrhea
• Loperamide: 1 tablet qAM or BID, increase if stools remain loose
• Bile acid sequestrant (e.g., colestipol)
• Pain
• Antispasmodic: hyoscyamine, dicyclomine, peppermint oil
• Tricylic antidepressant: nortryptyline/desipramine 10 mg Qhs, increase
up to 50 mg Qhs
• Bloating
• Probiotic (bifidobacter infantis, combination probiotics, etc. )
Ford A, Lacy B, Talley N. N Engl J Med 2017; 376:2566-257
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Polyethylene Glycol (PEG) Improves Bowel But Not Abdominal Symptoms in IBS-C
Chapman RW, et al. Am J Gastroenterol. 2013;108(9):1508-1515.
Spontaneous Complete
Bowel Movements (SCBMs)Abdominal Discomfort/Pain
*P<.0001.
N=68 N=71
• Between 1 and 3 sachets of PEG 3350 + E (13.8 g per day) or matching placebo
were administered
• Patients adjusted the dose based on stool consistency
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Mechanism of Action:Secretogogues for IBS-C
Tack J, Gastroenterology 2018;155:1677–1691
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FDA Endpoint Responder rates
>30% improvement in abdominal pain + >1CSBM /wk
Efficacy of Secretogogues in IBS-CSystematic Review and Network Meta-analysis
Black CJ et al. Gastroenterology2018 Dec;155(6):1753-1763.
“Efficacy was similar among individual drugs and dosages for most end points.”
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Tenapanor 50 mg BID Improves IBS-C Symptoms
• Tenapanor is a minimally absorbed sodium/hydrogen exchanger isoform 3 inhibitor (NHE3)
• Phase III Clinical Trial (12 weeks; 4 week randomized withdrawal)
• FDA Approved for IBS-C (Sept. 2019)
Chey W, Lembo A, Rosenbaum D al. AJG in press 2019
6/12 week responders
9/12 week responders
FDA Responder
>30% abdominal pain +
>1 CSBM /wkCOPYRIGHT
Tegaserod, 5-HT4 partial agonist, Improves IBS-C Symptoms
• FDA reapproved (Sept.
2019) 6 mg BID for women
< 65 years
• Contraindicated in
patients with h/o MI,
stroke ,TIAs, or angina, or
ischemic colitis, ESRD,
hepatic impairment (Child-
Pugh B or C)
Chey W, Am J Gastroenterol 2008;103:1217–1225
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Mechanism of Action: IBS-D Treatments
Opioid receptor modulatorsLoperamide (mu agonist)
Eluxadoline * (mu-agonist, delta-antagonist
Modulation of gut floraRifaximin *
Probiotics
Neuromodulators TCAs/SNRIs
Pre-gabalin
5-HT3 antagonistsAlosetron *
Ondansetron
Bile acid binding agentsCholestyramine
Colestid/Colesevelam
Antispasmodics
Anti-cholinergics
Peppermint oil
*FDA-approved for management of IBS-D.
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”We found all drugs to be superior to placebo, but alosetron and ramosetron
appeared to be the most effective.”
Black CJ et al. Gut 2019 Apr 17. pii: gutjnl-2018-318160
Efficacy of IBS-D TreatmentSystematic Review and Network Meta-analysis
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Phase III Clinical Trials: Eluxadoline for IBS-D
FDA Responder
≥30% improvement of abdominal pain and stool consistency score of BSS type <5 for ≥50% of daysR
esp
on
ders
, %
Δ 9.5†
Δ 10.3†
Δ 7.2†
Δ 11.5†
Wk 1–12 Wk 1–26
35
30
25
20
15
10
5
0
n=808 n=806 n=809 n=808 n=806 n=809
16.7 26.2 27.0 19.5 26.7 31.0
PBO
75mg ELX
100mg ELX
†P<.001
Lembo A et al. N Engl J Med. 2016;374(3):242-253
Lembo A, et al. N Engl J Med. 2016; 374: 242-53
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Eluxadoline
• Constipation: 7-8%.
• Pancreatitis in 0.3% (5/1457)
• Sphincter of Oddi Dysfunction in 0.5% (8/1457)
• All cases of pancreatitis/SOD occurred in patients
without a gallbladder or increased ETOH use
• Eluxadoline is contraindicated in patients without a gallbladder (cholecystectomy) or
> 3 alcohol drinks/day;
471. Viberzi (eluxadoline) [prescribing information]. Allergan USA, Inc. Irvine, CA; 2019; 2. Cash B, et al. Am J Gastroenterol. 2017; 112: 365-374.
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• Black-box warning: serious GI effects
• Ischemic olitis
• 2 per 1000 pts over 3 months
• 3 per 1000 pts over 6 months
• Constipation
• Alosetron (1 mg bid) = 29%
• Placebo = 6%
• Prescribing Program
• 0.5 mg BID, increase 1 mg BID if
tolerated
Alosetron [package insert]; 2016
*P<0.02vsplacebo
Assessmentat12weeks
GIS=Global ImprovementScale
Safety Profile of Alosetron
Krause R et al. Am J Gastroenterol 2007; 102:1709
Alosetron, a 5-HT3 antagonist, Improves Global Symptoms in Women with Severe IBS-D
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Ondansetron* for IBS-DData From a Single Center Study
Garsed K, et al. Gut. 2014;63:1617-25.
**Randomized, double-blind, dose-titration study. Primary endpoint was
average stool consistency in last 2 weeks of treatment. Improvements in
urgency, frequency, bloating but NOT pain.
*Off-label
Bri
sto
l S
tool
Form
Score
Effect of Ondansetron 4 to 8 mg TID for 5 Weeks
in Patients With Rome III IBS-D (N = 120)**
Treatment 1 Treatment 2Washout
Endpoint Weeks Endpoint Weeks
Crossover
4
6
5
3
2
1
Ondansetron
Placebo
7
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GI Society Guidelines for IBS Treatment
Medication Society Recommend
ation
Quality of
Evidence
Comments
Antispasmodi
cs
AGA1,2 Conditional Low Low cost, wide availability, minimal adverse
effects
ACG3 Weak Very low
Low*
Adverse events were dry mouth, dizziness,
and blurred vision
Tricyclics AGA1,2 Conditional Low Used with caution in pts with prolonged QT
ACG3 Strong High Effective in relieving pain and overall sxs,
Limited by patient acceptance and side effects
SSRIs AGA1,2 Conditional
against
Low No improvement in abdominal pain
ACG3 Weak Low Effective in relieving pain and overall sxs,
Limited by patient acceptance and side effects
Diet ACG3 Weak Very low Low FODMAP and gluten free or exclusion
diet based on antibody or leukocyte activation
test for overall sx improvement
Probiotics ACG3 Weak Low Improve global sx, bloating, flatulence
Psychological ACG3 Weak Very low Overall sx improvement; some have absence
of true sham control, may be therapist
dependent
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Neuromodulator for IBS and FBDs
SSRIs TCAs SNRIs
Consider when anxiety, depression, and phobic features are prominent with
FGIDs
Treatment when pain is dominant in FGIDs or when side effects from TCAs preclude
treatment
First-line treatment when pain is
dominant in FGIDs
Tetracyclic antidepressan
t
Treatment of early satiety, N/V, weight loss and disturbed
sleep
(paroxetine, fluoxetine, sertraline, citalopram,
escitalopram)
(amitriptyline, nortriptyline, imipramine,
desipramine)
(duloxetine,venlafaxine,
desvenlafaxin, milnacipran)
(mirtazapine, mianserin, trazodone)
Drossman DA et al. Gastroenterology 2018;154:1140–1171
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Standard CBT (s-CBT) (n=146)
10 wkly sessions
Minimal Contact (MC-CBT) (n=145)
4 session of home based CBT
Education control (n=145)
4 sessions education
Cognitive Behavioral Therapy for IBS
Lackner J, Gastroenterology. 2018 Jul; 155(1): 47–57.
Global Improvement at week 12
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First Line Treatment for IBS
• Constipation
• Fiber (soluble): 5 g QD – increase if tolerated to 10 g
• Polyethylene glycol: 17 g QD, titrate until stools are soft but formed
• Diarrhea
• Loperamide: 1 tablet qAM or BID, increase if stools remain loose
• Bile acid sequestrant (e.g., colestipol)
• Pain
• Antispasmodic: hyoscyamine, dicyclomine, peppermint oil
• Tricylic antidepressant: nortryptyline/desipramine 10 mg Qhs, increase
up to 50 mg Qhs
• Bloating
• Probiotic (bifidobacter infantis, combination probiotics, etc. )
Ford A, Lacy B, Talley N. N Engl J Med 2017; 376:2566-257
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Summary of RCTs of FMT in IBS
• Recent meta-analysis: no difference between placebo and
FMT (51% vs. 49% response rate; 4 trials; n = 254)
• NJ or colonoscopic administration > greater efficacy
• Abstract presented at UEG week 2019
• Super donor with ‘favourable fecal microbial profile (Norway)
• 164 IBS moderate/severe symptoms (IBS-SSS score < 175
• Proximal duodenum via gastroscope
• Clinically significant improvement: 5.5% placebo vs. 35.2% FMT
30g vs. 47.3% FMT 45g
Xu et al, Am J Gastroenterol 2019; El-Salhy et al. UEG week 2019
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Conclusions• IBS is a chronic pain condition due to disregulation in brain-
gut axis
• Cornerstone of treatment include a therapeutic clinician patient relationship, dietary modifications, increase exercise and stress reduction
• First line treatment is based on predominant symptom• IBS-C: PEG + fiber
• IBS-D: loperamide
• Pain: Anti-spasmodics or TCA
• Other treatments including prescription medications and psychological therapies are available for persistent symptoms
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