The American Gastroenterological Association (AGA) has released a new guideline that includes recommendations on drugs for the treatment of irritable bowel syndrome (IBS). The document, which was recently published in the Gastroenterology journal, aims to help patients as well as physicians decide the best treatments for the disease’s symptoms, and the association believes that it provides an evidence-based tool to improve patients’ health.
The expert team responsible for the new guidelines examined data from recently published IBS studies in order to evaluate the ones they believed offered the best data quality, as well as a balance between the risks and benefits that support the use of a particular drug. The researchers used the Institute of Medicine’s Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to conduct this evaluation.
“Because no IBS therapy is uniformly effective, many patients describe a history of a variety of treatments alone or in combination. This guideline will help patients and physicians navigate the drug options. It’s also important to consider other clinically relevant information, such as a patient’s values and preferences, when making treatment decisions,” explained one of the authors of the guideline, Shahnaz Sultan, who is an assistant professor of medicine at the University of Florida College of Medicine and the Department of Veteran Affairs Medical Center of the North Florida/South Georgia Veterans Health System.
Irritable bowel syndrome comprises a series of symptoms affecting the function of the gastrointestinal tract, including cramps, gas, bloating, changes in bowel habits, constipation, and diarrhea. The causes are unknown, but it can lead to the development of more severe diseases, like cancer of inflammatory bowel diseases (IBD). Even though for most of 15% of the adult population who suffer from IBS, the symptoms are typically only unpleasant, they can also be disabling.
Different Drugs, Different Recommendations
The results of the research, as analyzed through the GRADE system, is divided by the authors into two sets of recommendations which have different implications for patients, physicians, and policy makers. The first class includes the strongest recommendations, meaning that there is a low probability that patients would need formal assistance to decide if the recommended course of treatment is suitable for them or not, since the majority of patients would want to be prescribed the recommended drugs.
For clinicians, this group is the one that most patients should be administered, and they are directed to follow the recommendations in line with the guideline, making them suitable to be used as a standard for assessing quality or performance. In most cases, physicians wouldn’t need to assist patients in their choice of treatment for this group of drugs. For policymakers, this group of strongly recommended therapies can often be used as the basis of policy in many public health situations.
On the other hand, the second class is the based on conditional or weaker recommendations, and can raise questions among the patient population, as not all patients will feel they are suitable for their particular situation, meaning that they most likely would need formal help in forming a treatment decision. Therefore, physicians would need to study the evidence and information available for this group of IBS drugs to assess the drug as an effective treatment for each patient and help them decide, while policymakers would need to debate it to formulate a policy, since it is not universal.
Each Symptom Has Its Own Treatment
Constipation is one of the most common symptoms of the disease, and for IBS with constipation (IBS-C) the guideline suggests the use of linaclotide over no drug treatment, classifying it as a strong recommendation, supported by high-quality evidence. As a conditional recommendation, lubiprostone is also recommended based on moderate-quality evidence, or of the use of laxatives, but based on low-quality evidence.
For patients who experience diarrhea (IBS-D), on the other hand, there is no strong recommendation from the AGA. However, the association suggests the use of rifaximin or alosetron, which are both classified as conditional recommendations and supported by moderate-quality evidence. Loperamide is offered as a conditional recommendation with very low-quality evidence.
Guidelines for IBS Patients Who Also Need Antidepressants or Antispasmodics
The use of antidepressants may help in the management of the symptoms of the condition, and therefore the AGA conditionally recommends the use of tricyclic antidepressants over no drug treatment, based on low-quality evidence. In addition, as a conditional recommendation also supported by low-quality evidence, the AGA suggests using selective serotonin reuptake inhibitors, or using antispasmodics over no drug treatment.
All in all, the researchers believe that the guideline comprises a rigorous, evidence-based, and helpful tool for both patients and physicians.
The association had already published a similar guideline document for Crohn’s disease to help gastroenterlogists conduct diagnosis and treatment choices, as well as support their clinical decisions. The “Identification, Assessment, and Initial Medical Treatment in Crohn’s Disease Clinical Decision Support Tool” was also the result of the revision of literature on the disease by an expert workgroup.
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