New & updated IBS management guidelines.
Hot off the press in April 2021, Gut journal has published the latest guidelines for the management of IBS, commissioned by the British Society of Gastroenterology (BSG). The last publication of these guidelines was in 2007 and this update has been much anticipated.
A diverse working group was involved in reviewing the guidelines, with the strength and quality of the evidence graded. We can use these updated guidelines to guide our clinical practice and to make sure the standards of care is the same for all with IBS.
A disorder of gut-brain interaction
First off to note is the re-classification of IBS, now being considered as a disorder of gut-brain interaction, rather than a functional gastrointestinal disorder. The emphasis on the bidirectional link between the gut and the brain in IBS is now very much part in helping to diagnose this complex condition.
Foundations of IBS Treatment
As part of first line, emphasis is placed on:
- Good communication
- Simple lifestyle
- Dietary advice
First Line Dietary Advice
Traditional dietary advice is considered first line and is based on National Institute for Health and Care Excellence and British Dietetic Association (BDA). See the link to the BDA Food Fact sheet here: https://www.bda.uk.com/resource/irritable-bowel-syndrome-diet.html
- Healthy eating patterns
- Regular meals
- Adequate nutrition
- Limiting alcohol
- Caffeine intake
- Adjusting fibre intake: Fibre was shown to have benefit in IBS, more specifically limited to soluble fibre, such as isphagula. Start with a low dose and build up gradually. Insoluble fibre, like wheat bran, may exacerbate abdominal pain and bloating.
- Reducing consumption of fatty and spicy foods
Second Line Treatment
The low FODMAP diet is recommended as a second-line diet for IBS. These include short-chain fermentable carbohydrates found in variety of fruits, vegetables, dairy products, artificial sweeteners and wheat. New trials comparing a low FODMAP diet helped with a reduction in symptoms when compared to control interventions.
Another exciting development is that a response to a low FODMAP diet may be predicted. Preliminary data from faecal bacterial profiling and metabolomics activity could be used as a tool to identify those who may benefit.
To learn more about how the low FODMAP diet works and the EATFIT low FODMAP program, click here: https://www.eatfitsa.com/fodmap-diet/
What about Probiotics?
We all want to know whether to advise our patients to supplement with probiotics and if so, which strain would be beneficial.
It is now known that the faecal microbiome of patients with IBS may differ significantly from that of healthy individuals. New trial data showed significant effects on global symptoms or abdominal pain for combinations of probiotics but it was difficult to give specific recommendations on species or strain.
Patients who would like to try probiotics can take them for up to 12 weeks and discontinue if there is no improvement in symptoms.
With a growing interest in non-diet therapies for our patients with IBS, there is compelling evidence for cognitive behavioural therapy (CBT) and gut-directed hypnotherapy. Both are recommended by the NICE guidelines when symptoms have not improved after 12 months of drug treatment.
Cognitive Behavioural therapy:
Successes from two recent and large trials, using CBT developed specifically for IBS, show benefit for both mental health and gastrointestinal symptoms. IBS-specific CBT may be an efficacious treatment for global symptoms in IBS.
For more guidance on what CBT is exactly: https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/cognitive-behavioural-therapy-cbt/overview/
This therapy aims to induce a deep state of relaxation and it may also be an efficacious treatment for global symptoms in IBS. The exact mechanisms in IBS are still uncertain primary aim of treatment is to lower the severity and impact of abdominal pain and to help regulate bowel habit.
If you would like more information on this type of therapy, check out this link: https://www.hypnotherapists.org.uk/hypnotherapy/hypnotherapy-for-ibs/
Other noteworthy recommendations
As part of first line drug therapy, peppermint oil could be of benefit in IBS. Peppermint oil could be effective for abdominal pain and global symptoms but gastro-oesphageal reflux is a possible side effect.
There was also no conclusive evidence for human gut microbiome profiling, the use of elimination diets based on IgG allergy testing and gluten free diets in IBS.
Finally, to be aware of those at high risk of overly restrictive eating behaviours and using simple screening tools if indicated before undertaking the low FODMAP diet.
All in all, a comprehensive review to guide our clinical practice to manage our IBS patients. Or course, the full article can be viewed here: https://gut.bmj.com/content/gutjnl/early/2021/05/24/gutjnl-2021-324598.full.pdf