Treatment of irritable bowel syndrome in primary care

Ford and colleagues’ meta-analysis on three very low-cost, low-
toxicity agents for irritable bowel syndrome—fibre, antispasmodic drugs,
and peppermint oil—represents an important contribution to clinical care.
(1) At just pennies per day, these options represent excellent first line
treatment options. Surprisingly, Professor Jones’ accompanying editorial
suggested that the effectiveness of these agents should further increase
interest in the pharmacotherapy of irritable bowel syndrome.(2)

However, with all due respect to our colleague Professor Jones, we
believe that the effectiveness of these agents should further increase
interest in other low-cast, low-toxicity interventions.

We are concerned by the heavy emphasis on pharmacotherapy found in so
many British and US irritable bowel guidelines. Here in the United States,
the cost of the 5-HT3 antagonist alosetron (for IBS with diarrhoea) at the
recommended 1 mg PO BID is $842 per month according to drugstore.com.(3)
Even if a future generic product approached the low cost of loperamide or
tricyclic agents, the emphasis on pharmacologic approaches to IBS results
in two avoidable negative consequences. First, this emphasis encourages
continuing monthly expenditures ad nauseum. Secondly, and most
importantly, this emphasis also encourages ongoing patient passivity and
dependence upon the medical system.

We believe that the emphasis on pharmacotherapy for IBS represents a
missed opportunity for patients to discover their own self-healing
capacity and develop self- responsibility for their own wellbeing.

Rather than emphasizing pills, what might happen if IBS guidelines
prioritized for patients the discovery and development of self-care skills
such as those taught in hypnotherapy and cognitive-behavioral therapy?

Hypnotherapy appears to relieve symptoms as well as or better than
pharmacotherapy, with no side effects. However, unlike pharmacotherapy,
hypnotherapy relieves more than symptoms: it also improves quality of life
and psychological status, including the sense of self-empowerment and self
-control, all of which which correlates with higher motivation for ongoing
self-care. (4) Furthermore, continual professional treatments are not
needed: the beneficial effects from the initial treatments appear to be
sustained over time, with patients reporting continued relief from
symptoms for at least five years. (5)

In Lackner and colleagues’ meta-analysis of 17 randomized trials of
hypnotherapy and cognitive behavioral therapies, as compared with control
treatments (including waiting list, symptom monitoring, and usual medical
treatment), the estimated number needed to treat (NNT) was merely two. (6)
This compares quite favorably with Ford and colleagues’ report on the NNT
for soluble fibre (11.5), antispasmodics (5), and peppermint oil (2.5).

Shouldn’t such results increase our interest in the low-cost, low-
toxicity, non-pharmaceutical therapies for irritable bowel syndrome? At
present, hypnotherapy and cognitive behavioral therapies are reserved for
treatment in secondary and tertiary care. Why not advance research on
their role in primary care? Why save the best for the worst?

Gregory A. Plotnikoff, MD, MTS
Medical Director
Penny George Institute for Health and Healing
Abbott Northwestern Hospital
Minneapolis, MN USA 55407

Mark B. Weisberg, PhD, ABPP
Clinical Health Psychologist
Minnesota Head and Neck Pain Clinic
St Paul, MN USA 55114

1) Ford AC, Talley NJ, Spiegel BMR, Foxx-Orenstein AE, Schiller L,
Quigley EMM, et al. Efficacy of fibre, antispasmodics, and peppermint oil
in irritable bowel syndrome: systematic review and meta-analysis. BMJ
2008;337:a2313.

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

3) www.drugstore.com accessed November 29, 2008.

4) Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in
irritable bowel syndrome: a large-scale audit of a clinical service with
examination of factors influencing responsiveness. Am J Gastroenterol
2002;97:954–61.

5) Gonsalkorale WM, Miller V, Afzal A, et al. Long term benefits of
hypnotherapy for irritable bowel syndrome. Gut 2003;52:1623–9.

6) Lackner JM, Mesmer C, Morley S, Dowzer C, Hamilton S.
Psychological treatments for irritable bowel syndrome: a systematic review
and meta-analysis. J Consult Clin Psychol 2004;72: 1100-3.

Competing interests:
None declared