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November 19, 2014
New IBS Guidelines Offer Some Advice, Few
Strong Recommendations  

Bethesda, MD—With up to 15% of American adults affected by irritable bowel syndrome (IBS), the most common diagnosis in clinical gastroenterology, pharmacists get a lot of questions about what treatments are most effective.

A new guideline from the American Gastroenterological Association (AGA) cautiously offers some answers. The article was published recently in the journal Gastroenterology.

“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,” said author Shahnaz Sultan, MD, MHSc, of the North Florida/South Georgia Veterans Health System in Gainesville, FL.

The guideline was developed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and best practices as outlined by the Institute of Medicine. All comparisons are to no drug treatment.

For IBS with constipation, the guidelines are:

• Recommend using linaclotide in patients with IBS-C (strong recommendation; high-quality evidence)
• Suggest using lubiprostone in patients with IBS-C (conditional recommendation; moderate-quality evidence)
• Suggest using lubiprostone in patients with IBS-C (conditional recommendation; moderate-quality evidence)

For patients with IBS and diarrhea, the guidelines are:

• Suggest using rifaximin in patients with IBS-D (conditional recommendation; moderate-quality evidence)
• Suggest using alosetron in patients with IBS-D to improve global symptoms (conditional recommendation; moderate evidence)
• Suggest using loperamide in patients with IBS-D (conditional recommendation; very low-quality evidence)

For IBS in general, the guidelines are:

• Suggest using tricyclic antidepressants in patients with IBS (conditional recommendation; low-quality evidence)
• Suggest against using selective serotonin reuptake inhibitors for patients with IBS. (conditional recommendation; low-quality evidence)
• Suggest using antispasmodics in patients with IBS (conditional recommendation; low-quality evidence)

The authors lament that they were unable to make more strong recommendations, noting, “Despite the large number of published studies, in most cases our recommendations are weak because either (1) the quality of the available data and/or (2) the balance of risks and benefits for a particular therapy do not overwhelmingly support its use.”

The report adds, “Given the growing focus on the need to show the comparative effectiveness of therapeutic alternatives, it is important to note that essentially no studies exist in this area comparing commonly used therapies with each other. Further, there are no substantial data comparing combinations of various therapies with placebo or with each other.”


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