Authors: Wang XJ, Thakur E, Shapiro J
Journal: BMJ
Year: 2024
Volume: 387
Article number: e075777
DOI: 10.1136/bmj-2023-075777
Study at a glance
- Study type: State of the art review
- Studies included: Multiple randomised controlled trials, systematic reviews, and meta-analyses
- Participants: Adults with irritable bowel syndrome
- Intervention: Non-pharmaceutical treatments including dietary interventions, brain-gut behaviour therapies, complementary and integrative health approaches, and emerging therapies
- Comparison: Varies by intervention: placebo, usual care, or alternative treatments
- Follow-up duration: Varies by study
- Main outcome(s): Global symptom improvement, abdominal pain, quality of life, bowel movement frequency and consistency
Why was this review done?
Irritable bowel syndrome is a chronic gut-brain condition causing abdominal pain and altered bowel habits. It affects roughly 4% of adults worldwide, with higher rates in women and younger people. Symptoms impact productivity by approximately eight days monthly and substantially reduce quality of life. Many patients seek non-pharmaceutical treatments due to preferences for natural approaches, medication concerns, or limited pharmaceutical effectiveness. Wang and colleagues reviewed evidence for common non-pharmaceutical treatments.
How was the review performed?
The authors searched medical databases from March 2013 to March 2023 for high quality randomised trials, systematic reviews, and meta-analyses on non-pharmaceutical irritable bowel syndrome treatments in adults. Studies were selected based on guideline inclusion, robust evidence, regulatory approval where relevant, and patient advocate consultation. Pharmaceutical treatments, basic science research, children, and low quality trials were excluded.
What did the researchers find?
Dietary interventions
Soluble fibre, particularly psyllium, improved global symptoms, benefiting roughly one in 10 people. Insoluble fibre showed no benefit. The low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet showed benefit in multiple studies. One trial comparing this diet with modified National Institute for Health and Care Excellence guidance found similar adequate relief rates, though the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols group showed greater improvements in pain, bloating, and quality of life. Another primary care trial found 71% of patients on the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet reported improvement at eight weeks versus 61% taking antispasmodics. The diet should be delivered in three phases: elimination, reintroduction, and personalisation, with eating disorder screening before starting.
Kiwifruit consumption increased bowel movements and reduced discomfort in constipation-predominant irritable bowel syndrome, though samples were small. One Mediterranean diet trial found 83% of participants reported reduced symptoms versus 37% continuing usual diet.
Dietary supplements
Glutamine supplementation in 54 post-infectious irritable bowel syndrome patients showed roughly 80% improvement versus approximately 6% with placebo. Vitamin D evidence was mixed.
Microbiome therapies
Probiotics showed benefits for global symptoms and pain but substantial strain variation prevented specific product recommendations. Guidelines offered conflicting advice. Faecal microbiota transplant showed no clear benefit and carries infection risks.
Brain-gut behaviour therapies
Cognitive behavioural therapy and gut directed hypnotherapy showed robust evidence. One large trial found telephone-delivered and web-based cognitive behavioural therapy improved symptom severity, quality of life, and mood versus usual care, with benefits sustained at 24 months. A systematic review identified these as the most effective psychological treatments. App-based gut directed hypnotherapy showed 64% of users experienced meaningful pain improvement.
Complementary approaches
Peppermint oil was more effective than placebo for global symptoms and pain, benefiting roughly one in four people. Common side effects were mild reflux and indigestion. Acupuncture evidence was mixed, with difficulty distinguishing true from sham treatment. Cannabis-based treatments showed no benefit and one database study suggested increased hospitalisation risk.
Traditional Chinese medicine formulation Tongxie Yaofang showed benefit, with one trial reporting 79% achieved pain reduction versus 32% on placebo.
Emerging therapies
Intestinal binding agent polymethylsiloxane polyhydrate showed benefit in diarrhoea-predominant irritable bowel syndrome, with roughly 37% meeting improvement criteria versus 24% on placebo. A vibrating capsule approved for chronic constipation is being studied. Vagal nerve electrical stimulation showed promise for pain and constipation.
What did the authors conclude?
Treatment has evolved substantially, with growing evidence for non-pharmaceutical options. International guidelines support dietary interventions as front-line therapy. Guidelines generally support brain-gut behaviour therapies, though recommendations vary. Complementary approaches including peppermint oil and traditional herbal therapies are gaining acceptance. Irritable bowel syndrome is varied and many approaches aim to provide personalised therapy within standardised frameworks. Future research should identify optimal protocols, dosages, durations, and determine which patients benefit most from specific interventions.
Key takeaways
- Soluble fibre, particularly psyllium, and the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet show benefit for irritable bowel syndrome symptoms, though restrictive diets should be implemented carefully with attention to nutritional adequacy and screening for eating disorders.
- Cognitive behavioural therapy and gut directed hypnotherapy are effective treatments with benefits lasting up to 24 months, and can now be delivered through digital platforms to improve access.
- Peppermint oil provides modest benefit for global symptoms and abdominal pain, with generally mild side effects such as reflux.
- Probiotics may help some patients but substantial variation in products and formulations makes specific recommendations difficult.
- Several emerging approaches including intestinal binding agents, electrical nerve stimulation, and virtual reality show promise but require further research.
This Scientific Publication Summary is an objective summary of the published study for personal and educational use. It does not constitute medical advice, endorsement of the intervention, or a recommendation to alter clinical practice.