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Treatment CQ 3-1.An RCT comparing the efficacy of soluble fiber (psyllium, ispaghula), insoluble fiber (bran), and placebo in IBS patients revealed that soluble fiber significantly improved abdominal pain and discomfort compared with placebo [94].In western coun- tries, several RCTs have revealed that a low fer-
mentable, oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet appears to be more effective than standard dietary advice for IBS patients [87, 88].The utility of probiotics in the treatment of IBS has been investigated in a large number of intervention studies including many high-quality systematic reviews, meta-analyses, and RCTs [113-122], but the results were somewhat inconsistent.With regard to dopamine D2 blocking agents, small-scale RCTs [106, 107] investi- gated the efficacy of domperidone in IBS patients and found no beneficial effect of this agent on gastroin- testinal symptoms.In other countries, several small-scale RCTs [108-110] and meta-analyses [103, 111] of anticholinergic agents indicate that anticholinergic agents are effective in improving gas- trointestinal symptoms including abdominal pain, although some reports do not appear to show improve- ment in overall symptoms [104, 112].In addition, a systematic review of 14 randomized studies reported that 1 h of yoga every day for 4 weeks, 0.5 h of walking almost every day for 12 weeks, and 0.5 to 1 h of aerobic exercise significantly improved IBS symp- toms [91].The efficacy of trimebu- tine maleate in patients with IBS was investigated in several small-scale RCTs [98-101] and meta-analyses [102, 103] conducted overseas.o Eliminating foods that exacerbate IBS symptoms, such as lipids, caffeine, spicy food, and milk and dairy products, is effective in managing IBS.It functions under acidic conditions as soluble fiber by absorbing water and thus potentially improving stool consistency [92].In Japan, tiquizium bromide, butylscopolamine bromide, timepidium bromide hydrate, and mepenzolate bromide have all been used as anticholinergic agents for the treatment of abdominal symptoms in IBS patients.If symptoms worsen after taking a particular meal, eliminating culprit foods from the diet is necessary, such as foods with high-fat content, caffeine, spicy foods, and milk and dairy products.In a Japanese phase III randomized controlled study, polycarbophil calcium was superior to trimebu- tine maleate in efficacy and equal in safety [93].This discrep- ancy in results may be attributable to methodological differences among trials, such as the type of probiotic used, duration of treatment, and outcome.This drug appears to improve gastrointestinal symptoms including abdomi- nal pain in IBS patients, although no overall improve- ment was observed.Comment: Trimebutine maleate acts on the peripheral l and j opioid receptors [96] and is a representative gastrointestinal modifier [97].Also, no clinical evi- dence is available on the efficacy of neostigmine or itopride in IBS patients.Some studies with probiotics versus placebo found an improvement in global symptoms with probiotics, while others failed to demonstrate a clear effect of probiotics.Comment: Twelve weeks of exercise significantly improved the symptoms and extraintestinal manifesta- tions of IBS in 102 patients [89].CQ 3-2.
Treatment
CQ 3–1. Is dietary therapy effective in treating IBS?
• Eliminating foods that exacerbate IBS symptoms,
such as lipids, caffeine, spicy food, and milk and
dairy products, is effective in managing IBS. Dietary
therapy is recommended for IBS. Weak recommen-
dation, evidence level B, 100% agreed.
Comment: Advice on regular dietary habits as a general
measure may be required for most IBS patients. If
symptoms worsen after taking a particular meal,
eliminating culprit foods from the diet is necessary,
such as foods with high-fat content, caffeine, spicy foods, and milk and dairy products. In western coun-
tries, several RCTs have revealed that a low fer-
mentable, oligosaccharides, disaccharides,
monosaccharides, and polyols (FODMAP) diet appears
to be more effective than standard dietary advice for
IBS patients [87, 88]. In Japan, evaluation of the low
FODMAP diet has not shown clear advantage to date
and requires further consideration.
CQ 3–2. Is behavioral modification other than change in
diet effective in treating IBS?
• Exercise therapy under proper instruction improves
IBS symptoms. Weak recommendation, evidence
level B, 92% agreed. There is no clear evidence for
the utility of other behavioral modifications, such as
eliminating alcohol and smoking or getting adequate
sleep.
Comment: Twelve weeks of exercise significantly
improved the symptoms and extraintestinal manifesta-
tions of IBS in 102 patients [89]. In the same
intervention group, increased physical activity for an
average observation period of 5.2 years had positive
long-term effects on IBS symptoms [90]. In addition, a
systematic review of 14 randomized studies reported
that 1 h of yoga every day for 4 weeks, 0.5 h of
walking almost every day for 12 weeks, and 0.5 to 1 h
of aerobic exercise significantly improved IBS symp-
toms [91].
CQ3-3. Is bulking polymer or dietary fiber intake effective
in treating IBS?
• Bulking polymer intake or dietary fiber intake is an
effective means of treating IBS. Bulking polymers or
dietary fiber is recommended for IBS. Strong
recommendation, evidence level A, 100% agreed.
Comment: Calcium polycarbophil is a hydrophilic
polyacrylic resin but is insoluble in water. It functions
under acidic conditions as soluble fiber by absorbing
water and thus potentially improving stool consistency
[92]. In a Japanese phase III randomized controlled
study, polycarbophil calcium was superior to trimebu-
tine maleate in efficacy and equal in safety [93].
Dietary fiber effectively improves the symptoms of
IBS. An RCT comparing the efficacy of soluble fiber
(psyllium, ispaghula), insoluble fiber (bran), and
placebo in IBS patients revealed that soluble fiber
significantly improved abdominal pain and discomfort
compared with placebo [94]. A systematic review and
meta-analysis confirmed the effect of soluble fiber in
treating IBS [95].
CQ 3–4. Are gastrointestinal motility modifiers effective in
treating IBS?
• Gastrointestinal modifiers are effective in treating
IBS. Gastrointestinal motility modifiers are recom-
mended for IBS. Weak recommendation, evidence
level B, 100% agreed.
Comment: Trimebutine maleate acts on the peripheral l
and j opioid receptors [96] and is a representative
gastrointestinal modifier [97]. The efficacy of trimebu-
tine maleate in patients with IBS was investigated in
several small-scale RCTs [98–101] and meta-analyses
[102, 103] conducted overseas. This drug appears to
improve gastrointestinal symptoms including abdomi-
nal pain in IBS patients, although no overall improve-
ment was observed. The use of trimebutine maleate is
generally recommended in some guidelines and
reviews [104, 105]. With regard to dopamine D2
blocking agents, small-scale RCTs [106, 107] investi-
gated the efficacy of domperidone in IBS patients and
found no beneficial effect of this agent on gastroin-
testinal symptoms. No studies have investigated the
utility of metoclopramide yet. Also, no clinical evi-
dence is available on the efficacy of neostigmine or
itopride in IBS patients.
CQ 3–5. Are anticholinergic agents effective in treating
IBS?
• Anticholinergic agents are effective in some patients
with IBS. Anticholinergic agents are recommended
for some patients with IBS. Weak recommendation,
evidence level B, 100% agreed.
Comment: Anticholinergic agents have antispasmodic
properties and are thought to be effective in the
treatment of IBS. In Japan, tiquizium bromide,
butylscopolamine bromide, timepidium bromide
hydrate, and mepenzolate bromide have all been used
as anticholinergic agents for the treatment of abdominal
symptoms in IBS patients. In other countries, several
small-scale RCTs [108–110] and meta-analyses
[103, 111] of anticholinergic agents indicate that
anticholinergic agents are effective in improving gas-
trointestinal symptoms including abdominal pain,
although some reports do not appear to show improve-
ment in overall symptoms [104, 112]. Anticholinergic
agents available in Japan may be more appropriate for
use in IBS treatment because of their slow-acting
properties. In addition, side effects of anticholinergics
such as thirst, constipation, and palpitation should be
considered when using them [105] .Probiotics are effective in treating IBS. Probiotics
are recommended for IBS. Strong recommendation,
evidence level A, 100% agreed.
Comment: Probiotics are defined as live microorgan-
isms that confer a significant health benefit to the host.
The utility of probiotics in the treatment of IBS has
been investigated in a large number of intervention
studies including many high-quality systematic
reviews, meta-analyses, and RCTs [113–122], but the
results were somewhat inconsistent. Some studies with
probiotics versus placebo found an improvement in
global symptoms with probiotics, while others failed to
demonstrate a clear effect of probiotics. This discrep-
ancy in results may be attributable to methodological
differences among trials, such as the type of probiotic
used, duration of treatment, and outcome. Overall,
probiotics are considered beneficial for IBS because of
their relatively low cost and safety.
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