G&H What are the most commonly used complementary and alternative medicine therapies among patients with irritable bowel syndrome?
LN A number of survey studies have been conducted regarding the use of complementary and alternative medicine (CAM) therapies among patients with irritable bowel syndrome (IBS). The largest of these studies is a national survey from 2012, which found that the most commonly used CAM therapies were herbs and supplements. Ginger, peppermint, and probiotics or digestive enzymes topped this category. Following herbs and supplements were mind-body therapies, which included gut-directed hypnosis, biofeedback, meditation, yoga, and tai chi, among other guided-imagery exercises. The third most common type of CAM therapies among IBS patients were manipulative-type therapies, such as chiropractic or osteopathic manipulation, massage, and craniofacial therapies. The survey reported that patients used CAM therapies regardless of IBS subtype, as the most common symptoms that these therapies were used to treat were pain and bloating, which are present irrespective of the IBS subtype.
G&H How prevalent is the use of CAM therapies among this patient population, and what are the predictors of CAM use?
LN The prevalence of CAM use among patients with IBS varies by study. In general, between 30% and 50% of patients with chronic gastrointestinal conditions, including IBS, will use CAM therapies. A majority of these patients use more than 1 modality, with research showing that approximately 50% of patients who use CAM therapies use 3 or more different modalities.
The predictors of CAM use are younger women, patients with a higher education, patients who have more severe symptoms, and patients who experience an overall feeling of poor satisfaction with standard therapy.
G&H What are the main reasons that patients with IBS might use CAM therapies?
LN The reasons for using CAM therapies are multifactorial. IBS tends to affect younger patients, who are more likely to consider CAM therapies as safer and more natural compared with standard therapies, which include prescription medications. The therapeutic gain of standard therapies over placebo is approximately 15%. Thus, a lot of patients either respond to placebo or are not satisfied with standard therapy and turn to other modalities.
G&H What have studies shown regarding the safety and efficacy of CAM therapies?
LN There is a lack of well-done randomized, placebo-controlled trials comparing the safety and efficacy of CAM therapies, which makes their use in IBS patients challenging. CAM therapies are not currently recommended by society guidelines, which are evidence-based. Gut-directed hypnosis has the greatest amount of supporting literature, with studies comparing it to standard therapy. These studies have found efficacy of gut-directed hypnosis over standard therapy, giving this CAM modality some traction. A recent study compared hypnosis and yoga to standard therapy and found that both of these CAM modalities were better than standard therapy but were equivalent to each other. Research from Johns Hopkins on the use of electroacupuncture for the treatment of IBS, constipation, and functional dyspepsia appears promising. However, most IBS trials have several hundred patients per arm, and trials on CAM therapies tend to be smaller.
G&H What is the general perception of gastroenterologists regarding the use of CAM therapies?
LN There is an increasing awareness of gut-directed hypnosis, peppermint oil, and dietary modifications (such as the low–fermentable oligosaccharide, disaccharide, and monosaccharide and polyol diet), as studies on these modalities have shown improvement in IBS symptoms. These results have led to a growing acceptance of complementary therapies and dietary modifications for patients with IBS.
G&H Are there any concerns with the use of CAM therapies in patients with IBS?
LN We know that 30% to 50% of IBS patients use CAM therapies for their symptoms, but nearly half of these patients do not tell their doctors. The most common reason in a study was that doctors did not ask their patients about CAM use, followed by patients thinking that their doctors did not need to know about their CAM use. A major concern is with patients who take herbs and supplements, as these medications can interact with other drugs. For example, some herbs can act as blood thinners, which doctors should be aware of if the patient is scheduled for surgery or needs to be prescribed a blood thinner for a different medical reason. Herbal blends may also contain toxicities. Therefore, doctors should ask their patients about CAM use and be aware of the potential side effects.
G&H Are there any contraindications to the use of CAM therapies?
LN Contraindications are dependent upon the specific CAM therapy. For instance, a lot of patients take peppermint oil for bloating. However, this therapy can cause acid reflux and worsening heartburn. If a patient has a herniated disc, yoga or manipulation therapy may not be the best option without first consulting a spine specialist. It is important for doctors to have an understanding of CAM therapies to help guide their patients.
G&H What are the main points of discussion that gastroenterologists should cover with their patients regarding CAM use?
LN The first step is to ask, and to be open to the fact that patients are using these CAM therapies. Most patients are getting their information from books, newspapers, friends, or the Internet, and very few are getting the appropriate information from their clinicians. A nonjudgmental conversation allows patients to explore their options; otherwise, they may choose not to disclose their CAM use, which could lead to harmful drug-drug interaction, as discussed previously. In terms of choosing therapies, clinicians should understand the advantages, disadvantages, and limitations of the various CAM modalities. There is no one-size-fits-all option, so the CAM therapy should be chosen based on the patient’s predominant symptom and any other comorbidities that he or she has. For example, hypnosis, biofeedback, or meditation may help ease a patient’s anxiety as well as his or her IBS symptoms. Clinicians should help guide their patients to incorporate CAM therapies into a more multimodal care plan.
G&H What are the priorities of research in this field?
LN Clinical trials are needed to evaluate the efficacy of CAM therapies. Patients pay out of pocket for most of these therapies, which can be fairly expensive. It would be beneficial to know if a better option is available for these patients. It would also be good to understand why these therapies may be helpful, as clinicians and patients are more likely to accept treatment when it can be demonstrated that the treatment has a purpose.
Dr Nguyen has served on the advisory board for Heron Therapeutics and Monash University, has consulted for Theravance Biopharma and Nevro, and has received research funding from Vanda Pharmaceuticals, Allergan, and electroCore.
Suggested Reading
Bahrami HR, Hamedi S, Salari R, Noras M. Herbal medicines for the management of irritable bowel syndrome: a systematic review. Electron Physician. 2016;8(8):2719-2725.
Dossett ML, Davis RB, Lembo AJ, Yeh GY. Complementary and alternative medicine use by US adults with gastrointestinal conditions: results from the 2012 National Health Interview Survey. Am J Gastroenterol. 2014;109(11):1705-1711.
Grudmann O, Yoon SL. Complementary and alternative medicines in irritable bowel syndrome: an integrative view. World J Gastroenterol. 2014;20(2):346-362.
Hussain Z, Quigley EM. Systematic review: complementary and alternative medicine in the irritable bowel syndrome. Aliment Pharmacol Ther. 2006;23(4):465-471.
Magge S, Lembo A. Complementary and alternative medicine for the irritable bowel syndrome. Gastroenterol Clin North Am. 2011;40(1):245-253.