Eluxadoline: a promising therapy that raises many questions

Abstract

IntroductionIn the United States (US) there are three medications currently approved for the treatment of irritable bowel syndrome (IBS)-D. The most recent additions, rifaximin and eluxadoline, were approved by the US Food and Drug Administration (FDA) on the same day in May, 2015, and were the first therapies approved by the FDA since the approval of alosetron in 2000. Rifaximin, approved for more than a decade for traveler's diarrhea and since 2010 for the prevention of recurrent hepatic encephalopathy, is well recognized by clinicians and has been used extensively as an off-label treatment for IBS and bloating, as well as for small intestinal bacterial overgrowth. Eluxadoline, however, represents a unique addition to the IBS-D therapeutic milieu and clinicians are just gaining experience with it since it became available in January of 2016. Eluxadoline is an orally administered, minimally absorbed mixed opioid receptor modulator, acting as a mu (μOR) and kappa opioid receptor agonist and delta opioid receptor (δOR) antagonist (1). It is thought that the μOR agonist component of eluxadoline reduces propulsive gastrointestinal motility and chloride secretion while the δOR antagonist component reduces both abdominal pain and opposes μOR activation, tending to 'normalize' bowel function rather than constipate (2). The significance of the kappa OR agonism of eluxadoline remains unknown.Lembo and colleagues recently reported the results of the phase 3 registration trials (IBS-3001 and IBS-3002) that supported FDA approval of eluxadoline in the January 21, 2016 issue of the New England Journal of Medicine (3). These two trials included 2,428 patients with IBS-D, defined in accordance with the Rome III criteria, who were randomized to receive 75 or 100 mg eluxadoline or placebo, all twice daily. Both trials evaluated efficacy during 26 weeks of double-blind treatment, following which the IBS-3001 trial continued for an additional 26 weeks of double-blind treatment in order to evaluate long-term safety, and the IBS-3002 trial concluded with a 4-week placebo withdrawal period to assess the effects of treatment cessation. The FDA composite endpoint of simultaneous daily improvement of both worst abdominal pain (≥30% improvement from baseline) and stool consistency (<50% of days with stool type 5 on the Bristol Stool Form Scale) over 1-12 weeks (FDA primary endpoint), and 1-26 weeks [European Medicines Agency (EMA) endpoint] was the primary endpoint of both trials. Pooled data from both trials showed that the primary FDA and EMA endpoints were met by significantly more patients treated with 100 mg eluxadoline than with placebo (25.1% vs. 17.1%, P<0.001 in IBS-3001 and 29.6% vs. 16.2%, P<0.001 in IBS-3002). For the FDA and EMA primary endpoints, patients treated with 100 mg eluxadoline experienced significantly higher responder rates for stool consistency, but not significantly higher responder rates for improvement in abdominal pain compared with placebo. Similar efficacy was seen in men and women and improvements in the...

The Microbiome and Irritable Bowel Syndrome – A Review on the Pathophysiology, Current Research and Future Therapy

“…Common side effects from the two phase 3 trials were constipation, abdominal pain, nausea, vomiting, abdominal bloating, and gastroenteritis. Long term usage was cautioned due to the occurrence of serious adverse events (SAEs) linked to eluxadoline use in 4% of the patients (Cash, 2016). From 2015 until 2017, 120 cases of pancreatitis were reported.…”

Alleviative effects of Bacillus coagulans strains on irritable bowel syndrome-unraveling strain specificity through physiological and genomic analysis

“…Multiple reports have linked IBS pathogenesis with dysbiosis caused due to transformation of commensal bacteria to pathogens in the human gut [45][46] . For instance, among the common trends reported in previous studies on the composition of intestinal bacteria in IBS subjects relative to healthy controls is the abundance of Bifidobacterium, Lactobacillus, Faecalibacterium, Erysipelotrichaceae, and Methanogens [47][48] .…”

Eluxadoline in irritable bowel syndrome with diarrhea: rationale, evidence and place in therapy

“…Direct comparison of eluxadoline with other recently approved IBS-D agents such as alosetron and rifaximin is not possible due to differences in the clinical trial methodologies and study populations. 23 Second-line prescription agents may include TCAs, which have not been as rigorously studied in IBS-D and have significantly more AEs than first-line agents. Potential advantages of eluxadoline include better quality evidence than loperamide and that its treatment not limited to use in only women as with alosetron; however, head-to-head studies directly comparing eluxadoline with other agents are currently lacking.…”