Review article: current and future treatment approaches for pain in IBS

Abstract

SummaryBackgroundAbdominal pain is a core symptom of IBS and a primary driver of care seeking. Visceral hypersensitivity is a key pathophysiological mechanism and therapeutic target for pain in IBS, with components of peripheral and central sensitisation and psychological factors.AimTo review current and future treatment approaches specifically for the pain component of IBS.MethodsPubmed search terms included combinations of irritable bowel, pain, visceral hypersensitivity, novel, new, emerging, future and advances.ResultsEstablished non‐pharmacological treatments for IBS pain include the low FODMAP diet, probiotics and psychological interventions, especially hypnotherapy. Tricyclics remain the best evidenced pharmacological approach with GCC agonists, tenapanor, lubiprostone, eluxadoline and 5HT3 antagonists second line according to patient characteristics and availability. Less well‐evidenced current options include anti‐spasmodics, peppermint oil, SSRIs, SNRIs, alpha 2 delta ligands, melatonin and histamine antagonists. Patients are vulnerable to iatrogenesis and harmful approaches to be avoided include opioids and unwarranted surgical interventions. For severe pain, the concept of augmentation with combined gut‐brain neuromodulators and psychotherapy in a multi‐disciplinary setting is considered. A plethora of molecular targets and ligands are emerging from pre‐clinical studies, together with early clinical evidence for a range of pharmacological, dietary, neurostimulation and novel psychological treatment delivery methods which are reviewed. The history of such emerging approaches, however, merits both caution and optimism in equal measure.ConclusionsDespite good in‐roads and emerging options, the management of abdominal pain remains one of the biggest challenges and research priorities for patients with IBS.

Long‐term personalized low FODMAP diet in IBS

“…Indeed, hypersensitivity together with an impaired gas transit and evacuation might generate symptoms such as pain and bloating 44 . However, the exact cause of visceral hypersensitivity has not been elucidated yet, even though central and peripheral sensitization, allodynia and hyperalgesia, together with psychological factors have been implicated in its genesis 7 . Indeed, it has been recently shown by fMRI that brains of IBS patients respond differently to fructan infusion in areas related to pain, such as the cerebellum, supramarginal gyrus, anterior and midcingulate cortex, insula and thalamus, highlighting the importance of a dysfunctional gut‐brain axis in IBS 45 .…”

“…Thus, dietary interventions are often proposed by clinicians or self‐administered by patients as initial therapeutic approaches to curb IBS symptoms. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is now considered by many a first‐line treatment option for IBS 7 . Despite growing number of randomized clinical trials assessing the efficacy of a low FODMAPs diet in reducing IBS symptoms, the quality of the evidence has been questioned, due to the likely presence of bias in dietary intervention trials 6 .…”

“…Despite growing number of randomized clinical trials assessing the efficacy of a low FODMAPs diet in reducing IBS symptoms, the quality of the evidence has been questioned, due to the likely presence of bias in dietary intervention trials 6 . However, a recent systematic review and network analysis demonstrated the superiority of the low FODMAP diet over alternative interventions, including British Dietetic Association (BDA)/National Institute for Health and Care Excellence (NICE) dietary advice 7 …”

Insight into Improved IBS Clinical Outcomes Using a Combination of Quantitative and Qualitative Research Methods to Better Understand Visceral Hypersensitivity and Treatments Addressing it

“…Cognitive behavioral gut-brain targeted treatment has gained popularity with improved symptom outcomes as well as self-help workbooks and apps [5,6]. Current treatment models developed around the growing acceptance of the gut-brain connection use hypnosis and cognitive therapy as key attributes to improving visceral hypersensitivity [23,24].…”

Biomolecules from Plant Wastes Potentially Relevant in the Management of Irritable Bowel Syndrome and Co-Occurring Symptomatology

“…While it was shown that an imbalanced and nutritionally deficient diet could promote, maintain, and worsen IBS symptoms [13], several studies have documented significant improvement in IBS symptomatology directly correlated with changes in dietary habits [14][15][16][17][18]. The FODMAP diet is just one of the current food plans used to alleviate IBS gastroenterological symptoms by assessing each aliment's implications following the IBS patient's tolerance to it or its benefits [19].…”