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Rapid response to:


Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis

BMJ 2008; 337 doi: (Published 14 November 2008) Cite this as: BMJ 2008;337:a2313

Rapid Response:

Treating irritable bowel syndrome: the old remedies are the best – so let’s not forget amitriptyline!

We read with interest the meta-analysis by Ford and colleagues (1).
This important study provides a much needed supportive evidence base for
our current practice. Jones also makes a critical point that a ‘holistic
and integrated approach’ is necessary (2). With this perspective in mind
we would like to make the suggestion that either within the ‘what is
already known on this topic’ of Ford’s paper or in the discussion, that
there should be the mention of the potential benefits of amitriptyline. At
low dose (10mg – 25mg nocte) it appears that some patients particularly
with diarrhoea predominant IBS derive symptomatic benefit. A recent meta-
analysis by the same authors has suggested a positive effect with a number
needed to treat of 4 (3). Although further work may be required in this
area – amitriptyline still remains an ‘old’ but important addition to the
clinicians’ armamentarium and is in keeping with a holistic approach when
considering therapeutic options in IBS patients (4).

1. Ford AC, Talley NJ, Spiegel BMR, Foxx-Orenstein AE, Schiller L,
Quigley EMM, Moayyedi P. Effect of fibre, antispasmodics and peppermint
oil in the treatment of irritable bowel syndrome: systematic review of the
literature and meta-analysis. BMJ 2008;337;a2313.

2. Jones R. Treatment of irritable bowel syndrome in primary care.
BMJ 2008;337:a2213.

3. Ford AC, Talley NJ, Schoenfeld PS, Quigley EM, Moayyedi P.
Efficacy of Antidepressants and Psychological Therapies in Irritable Bowel
Syndrome: Systematic Review and Meta-analysis. Gut 2008. Nov 10 [Epub
ahead of print].

4. National Institute for Health and Clinical Excellence. Irritable
bowel syndrome in adults. Diagnosis and management of irritable bowel
syndrome in primary care. London: NICE, 2008.

Competing interests:
None declared

Competing interests: No competing interests

18 December 2008
John S Leeds
Specialist Registrar in Gastroenterology
Clare M Leeds, David S Sanders
Royal Hallamshire Hospital, Sheffield, S10 2JF, UK