Complementary and Alternative Medicine for Irritable Bowel Syndrome

Educational Objectives

The goal of this program is to improve management of irritable bowel syndrome (IBS) using complementary and alternative medicine (CAM) approaches. After hearing and assimilating this program, the clinician will be better able to:

1. Incorporate CAM therapies into the management of IBS.
2. Identify benefits and risks associated with CAM therapies commonly used for IBS.

Summary

Complementary and alternative medicine (CAM) for irritable bowel syndrome (IBS): complementary medicine is used in conjunction with conventional therapies; medical foods and lifestyle modifications have moved into the mainstream; alternative therapies are used in place of conventional therapies and are still largely considered to be outside of mainstream practice; van Tilburg et al (2008) surveyed patients with IBS and found that 35% reported using CAM; use was highest among women, individuals with higher education, and those with more anxiety about their symptoms; ≈75% of patients did not inform their provider about their use of CAM, and 80% of providers did not inquire about patient’s use of CAM

Source of information: study published in 2015 found that ≈33% of individuals learn about CAM therapies from the media, and ≈25% learn from the internet; patients also take advice from family and friends; 50% of patients liked CAM approaches because they seemed more natural, and 25% preferred CAM because traditional approaches did not help; ≈65% reported a fair degree of satisfaction with their CAM therapies and ≈20% reported unsatisfactory results, but 81% were willing to try CAM again

CAM approaches to IBS: medicine is moving toward an integrative approach and use of mind-body medicine; categories include dietary approaches (eg, low-FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides and polyols] diets), psychological-based therapies (eg, hypnotherapy, cognitive behavioral therapy [CBT]), and natural products (eg, herbals, probiotics, medical foods, traditional Chinese medicine); the 2009 Task Force on IBS from the American College of Gastroenterology (ACG) gives a strong recommendation (grade 1B supported by moderate evidence) for psychological therapies, including CBT, dynamic psychotherapy, and hypnotherapy

Gut-directed hypnotherapy: uses subconscious suggestions, usually repetitive, to control and normalize gastrointestinal (GI) function and induce relaxation; the therapist provides suggestions for imaginative experiences and suggests changes to the subjective experience (processing of symptoms); therapy can be performed at home, in person, or online; metaphors and visualization techniques are used to treat pain and bowel habits; a meta-analysis (Peters et al [2015]) that included 7 heterogenous studies of different therapies found that high-volume gut-directed hypnotherapy (ie, large number of sessions) was superior to lower-volume gut-directed hypnotherapy, but low frequency (measured as times per week) was as effective as high frequency; group hypnotherapy was as effective as individual and online therapy

Cognitive behavioral therapy: techniques are aimed at modifying arousal; CBT is relaxation training that provides coping mechanisms and focuses on the present, whereas dynamic psychotherapy explores the patient's past, interpersonal issues, and experiences; it corrects deficits in skills that make patients vulnerable to catastrophizing about their physical symptoms; repetitive sessions are conducted over 3 to 4 mo; CBT can be conducted online, in person, or with self-help books

Mindfulness meditation: a study found increasing benefit over time for IBS

Acupuncture: traditional Chinese therapy based on the theory of an energy (or life force) called qi that runs through the body in channels called meridians; the aim is to restore the flow of qi at identifiable anatomic locations; electroacupuncture is also used; there is physiologic evidence to show effects on visceral reflex activity, gastric emptying, and acid reflux in some patients; a systematic review of 17 randomized controlled trials (RCTs; Manheimer et al [2012]) found no clear benefit for IBS symptoms with acupuncture compared with sham acupuncture; both groups had better improvements than patients who were placed on a waitlist for therapy, suggesting a large placebo response of acupuncture; most data do not support use of acupuncture for most patients with IBS

Traditional Chinese therapy: popular but unproven for IBS; a meta-analysis showed superiority to placebo for relief of global IBS symptoms, but there was a high adverse event rate (mostly mild); both Western and Eastern data on these therapies are biased

Herbal therapies: have not been widely studied; aloe — used as a stimulant laxative and may have analgesic and anti-inflammatory properties; a meta-analysis of 3 studies showed improvement in IBS symptoms; adverse effects include diarrhea, hepatitis, and interactions with diabetes medications and anticoagulants; cannabis — inhibits excitatory neurons and stimulates cannabinoid type 1 (CB1) and CB2 receptors; there are no convincing data to support use for IBS; adverse effects include cannabis hyperemesis and psychiatric symptoms; some patients improve with nontetrahydrocannabinol (THC)-based cannabinoid therapies; 9-herb oral herbal supplement (Iberogast) — thought to act as a spasmolytic; one RCT showed efficacy; it is used for dyspepsia-like symptoms; sedation, hepatitis, and acute liver failure can occur; turmeric — has anti-inflammatory properties; ≤2 g/day can be given in divided doses; a meta-analysis showed no difference compared with placebo for IBS; adverse effects are minimal

Dietary additives: glutamine is thought to help restore tight junctions and the gut barrier; the dose is 5 mg 3 times daily; one RCT suggested improvement compared with placebo and minimal adverse effects; melatonin (a sleep aid) may help in some patients; vitamin D supports the gut barrier and may affect the microbiome; prebiotics and probiotics may restore the microbiome (although the composition of a normal microbiome is not well understood); although data are not conclusive, some patients experience benefit; the American Gastroenterological Association does not recommend probiotics outside of a research study; the ACG stated that they may help IBS symptoms; prebiotics are a substrate selectively used by host microorganisms, eg, FODMAPs; synbiotics are combinations of prebiotics and probiotics (microorganisms thought to convey benefit to the host)

Take-home message: a recent meta-analysis of 66 trials assessing CAM for IBS found many CAM therapies (especially herbal therapies) are beneficial for abdominal pain; data support peppermint oil as an antispasmodic; data suggest benefits of mind-body therapy; no benefit has been shown for body-based or energy healing; use shared decision-making with patients

Readings

American College of Gastroenterology Task Force on Irritable Bowel Syndrome, Brandt LJ, Chey WD, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009;104 Suppl 1:S1-S35. doi:10.1038/ajg.2008.122; Ballou S, Keefer L. Psychological interventions for irritable bowel syndrome and inflammatory bowel diseases. Clin Transl Gastroenterol. 2017 Jan;8(1):e214; Billings W, Mathur K, Craven HJ, et al. Potential benefit with complementary and alternative medicine in irritable bowel syndrome: A systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1538–1553.e14; Gaylord SA, Palsson OS, Garland EL, et al. Mindfulness training reduces the severity of irritable bowel syndrome in women: Results of a randomized controlled trial. Am J Gastroenterol. 2011 Sep;106(9):1678–1688; Kinsinger SW. Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights. Psychol Res Behav Manag. 2017;10:231–237; Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2012;5(5):CD005111. Published 2012 May 16. doi:10.1002/14651858.CD005111.pub3; Paoletti A, Gallo E, Benemei S, et al. Interactions between natural health products and oral anticoagulants: spontaneous reports in the Italian surveillance system of natural health products. Evid Based Complement Alternat Med. 2011;2011:612150. doi:10.1155/2011/612150; Peters SL, Muir JG, Gibson PR. Review article: gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease. Alimentary Pharmacology and Therapeutics. 2015 June;41(11):1029-1225; Su GL, Ko CW, Bercik P, et al. AGA clinical practice guidelines on the role of probiotics in the management of gastrointestinal disorders. Gastroenterology. 2020;159(2):697-705; van Tilburg MAL, Palsson OS, Levy RL, et al. Complementary and alternative medicine use and cost in functional bowel disorders: a six month prospective study in a large HMO. BMC Complement Altern Med. 2008 Jul 24;8:46.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Cash was recorded at the 47th Annual Texas Meeting, held on September 23-25, 2022, in Austin, TX, and presented by the Texas Society for Gastroenterology and Endoscopy. For information on future CME activities from this presenter, please visit tsge.org. Audio Digest thanks the speakers and Texas Society for Gastroenterology and Endoscopy for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE370601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.