Advances in diagnostic testing and therapeutic options for irritable-bowel syndrome (IBS) has led the American College of Gastroenterology (ACG) to develop the first-ever clinical-practice guideline for managing the disorder. "We believe that these new IBS guidelines can be effectively used in daily practice to help expedite care and to improve symptoms in patients with IBS," co-author Dr. Brian E. Lacy of Mayo Clinic Jacksonville, in Florida, said in a statement. IBS is common chronic disorder of bowel function affecting an estimated 4.4% to 4.8% of the population and leading to reduced quality of life. In developing the guideline, the ACG guideline panel used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to critically evaluate available data for 25 clinically relevant questions; nine focused on diagnostic testing and 16 focused on treatment options. The guideline is published in the American Journal of Gastroenterology. Among the 25 recommendations contained in the guideline: - Do serologic testing to rule out celiac disease (CD) in patients with suspected IBS and diarrhea. - Check fecal calprotectin, fecal lactoferrin and C-reactive protein in patients without alarm features and with suspected symptoms of IBS and diarrhea to rule out inflammatory bowel disease (IBD). - Don't do routine stool testing for enteric pathogens in all patients with IBS. - Don't do routine colonoscopy in patients with IBS symptoms younger than age 45 who do not have warning signs. - Use a positive diagnostic strategy (as opposed to a diagnostic strategy of exclusion) for patients with IBS symptoms to improve time to treatment and reduce costs. - Don't test for food allergies and food sensitivities in all patients with IBS unless there are reproducible symptoms concerning for a food allergy. - Do anorectal physiology testing in patients with IBS and symptoms suggestive of pelvic flood disorder and/or refractory constipation. - Consider a limited trial of a low-FODMAP diet to improve global symptoms. - For treat IBS symptoms, options to consider include soluble (not insoluble) fiber, peppermint, tricyclic antidepressants and gut-directed psychotherapies; don't use antispasmodics, probiotics, polyethylene glycol (PEG) products or fecal transplant. - For global IBS with constipation (IBS-C) symptoms, use chloride channel activators and guanylate-cyclase activators. - For global IBS with diarrhea (IBS-D), options include bile-acid sequestrants, rifaximin and opioid agonists/antagonists; in women with severe refractory IBS-D, try alosetron. "We believe that the information provided in this guideline will help guide both practitioners and researchers for years to come. However, as this extensive project evolved, we recognized that there are still significant gaps in our knowledge," the guideline panel writes. "Future research is needed to better understand the role of the gut microbiome in patients with IBS and to understand the genesis of visceral pain. Identification of biomarkers to predict treatment response is also essential," they add. "Large head-to-head trials comparing different therapeutic modalities are also need to better provide individualized care. Undoubtedly, information obtained from these studies will influence new guidelines, assist in pharmaceutical and diet development, direct changes in study design, and inform regulatory agencies," the panel concludes. —Reuters Staff Source
