William D. Chey, MD – Michigan Medicine
Jordan Shapiro, MD – Baylor Houston
Jill Deutsch, MD – Yale University
For patients with irritable bowel syndrome (IBS), symptom management is often a marathon, not a sprint. Although IBS is one of the most common indications for patients to see gastroenterologists, only 30% of individuals with IBS seek medical attention. In additional to physician-directed therapies, many patients look to complementary and alternative medicine (CAM) for treatment of their IBS. Studies assessing CAM use by patients with IBS date back to 1986, span the globe, and report a prevalence of CAM use of approximately 50% (range of 16% to 73%).
What are CAM Therapies?
The breadth of therapies falling under the umbrella of CAM is vast, and the National Institutes of Health National Center for Complementary and Integrative Health provides some order by dividing CAM into natural products and mind-body medicine (see Table 1).
The NIH has defined complementary treatments as those used in addition to, and alternative treatments as those that substitute for, standard medical treatments. In the context of IBS, the classification of well-established mind-body modalities such as cognitive-behavioral therapy and gut-directed hypnosis as “alternatives” to standard treatments is a misnomer, as these constitute first-line therapies with some of the strongest evidence for the treatment of IBS. Thus, they may be used as primary treatment or to complement the traditional use of medications. Despite the commonality of CAM use by patients with IBS, most gastroenterologists receive little to no formal training regarding the use of these therapies.
|Table 1. Examples of CAM therapies for the treatment of IBS|
Artichoke leaf extract
Cognitive behavioral therapy
|Traditional medicinal systems
Traditional Chinese Medicine
Why Do Patients Use CAM?
Patients often view CAM as “more natural” and state they “wish to feel better” as a major reason for straying from more mainstream treatment options. In particular, concerns about the safety of prescription medications, particularly when used over the long term, is another important driver of CAM use amongst IBS patients. Patient perception of benefit from CAM therapies for IBS is highly variable, ranging from 16 to 80%. Curiously, though one study reported that only 16% of patients reported full satisfaction with CAM therapies, 81% of survey respondents stated that they would use the same CAM therapy again.
Talking with Patients About CAM
Communication between patients and their western medicine providers regarding CAM therapies is often disjointed. For example, 70% of patients discussed the decision to use CAM with their western medicine providers while in another study, only 19% of patients using CAM did so at the recommendation of a western medicine provider. Patients recruited from a large academic GI clinic in the northeast reported that the most common reason for not discussing CAM was a failure of their physicians to present CAM treatment options. Communication regarding the use of CAM therapies for IBS or other medical conditions is critically important as some of these treatments can lead to adverse events and/or lead to drug interactions.
Guidance on CAM Therapies for IBS
It is beyond the scope of this blog post to delve into specific CAM therapies for IBS. However, several recent publications have summarized the literature on natural products and mind-body therapies to treat IBS, and these have been included in references at the end of this posting1-5. The evidence base supporting the efficacy of acupuncture, supplements, herbal therapies, and behavioral interventions for a number of digestive disorders, including IBS and chronic constipation, is gradually growing. Going forward, it will be important to hold practitioners and manufacturers of CAM therapies to the same standards which apply to other over-the-counter and prescription medications.
In addition, it is important to note the controversy surrounding CAM for a number of reasons including the lack of regulation of natural products, limited or conflicting evidence, inconsistent manufacturing quality assurance, safety concerns (both intrinsic to natural products and related to interactions with drugs and other supplements), costs, pill burdens of patients taking large numbers of supplements, and the missed opportunity of forgoing more evidence-based therapies. Our recommendations are based not on unparalleled support in favor of or against these therapies, but rather to facilitate a partnership that is well-informed and patient-centered.
In order to partner with patients, providers must be able to elicit information about patients’ CAM therapy use, have a plan for monitoring efficacy and safety during the use of CAM therapies, and access appropriate resources to educate themselves on specific therapies (Table 2).
|Table 2. Tips on approaching CAM use in patients with IBS|
|Ask all patients about CAM use
● Any CAM use?
● Specific CAM therapies used for IBS (past, present, intended future)?
● How patients became interested/aware of CAM therapies?
● Effectiveness of CAM therapies for IBS symptoms? Which symptoms?
● Any adverse events related to CAM therapies?
|Steps on guiding patients through trial/use of CAM therapies
Patients with IBS have many reasons for pursuing the use of CAM therapy and often do so without discussing this decision with their western medicine health care providers. As is the case with the general care of patients with IBS, it is critical that providers work to understand patient perceptions of and preferences for the full spectrum of treatment options in order to work together towards use of standard and CAM therapies to improve symptoms and quality of life in a safe manner.
- Deutsch JK, Levitt J, Hass DJ. Complementary and Alternative Medicine for Functional Gastrointestinal Disorders. The American journal of gastroenterology. 2020;115(3):350-364.
- Fifi AC, Axelrod CH, Chakraborty P, Saps M. Herbs and Spices in the Treatment of Functional Gastrointestinal Disorders: A Review of Clinical Trials. Nutrients. 2018;10(11).
- Keefer L, Palsson OS, Pandolfino JE. Best Practice Update: Incorporating Psychogastroenterology Into Management of Digestive Disorders. Gastroenterology. 2018;154(5):1249-1257.
- Riehl ME. The Emerging Role of Brain-Gut Therapies for Irritable Bowel Syndrome. Gastroenterology & hepatology. 2018;14(7):436-438.
Shapiro JM, Deutsch JK, Chey WD. An evidence-based review of oral supplements for the treatment of patients with IBS. Neurogastroenterol LATAM Re. 2020;4:in press.