Presenter: Ali Keshavarzian, MD, Director, Division of Digestive Diseases, Rush University Medical Center, Chicago
For better or worse, primary care physicians are encountering increasing numbers of patients who are using complementary and alternative medicines (CAMs) for gastrointestinal syndromes. The use of these agents has exploded over the last decade. Dr. Keshavarzian quoted the 2007 National Health Interview Study from CDC, which revealed that nearly 4 in 10 adults had used a CAM treatment within the past year. This prevalence favors an open-minded approach to these patients, who often don’t disclose their use of CAMs out of concern that their physician will scoff at the modality’s lack of scientific validity. Since many ingested CAMs are biologically active, it is imperative that primary care physicians foster open communication with patients about their use.
The use of CAM for irritable bowel syndrome (IBS) comprised the bulk of the discussion. Research suggests value for a minority of CAM interventions, but with some treatments, clear dangers exist. Much of the now-sizable body of CAM research is limited by methodological flaws, and few randomized, double-blinded, and placebo controlled studies are available. Nonetheless, 11% to 53% of patients with IBS have tried at least one CAM technique:
• Hynotherapy and cognitive-behavioral techniques: Evidence supports the value of “mind-body” interventions, primarily for gut-directed hypnotherapy. A recent review of 11 studies found significant improvement of IBS symptoms in at least half of patients undergoing hypnotherapy, despite poor understanding of a mechanism of action for the effect.1 A randomized controlled trial of a cognitive-behavioral technique known as “mindfulness training” demonstrated substantial therapeutic effect on bowel symptom severity, reduced distress, and improved health-related quality of life.2 The beneficial effects persisted for at least 3 months after training.
• Probiotics, prebiotics, and diet: A recurrent theme of this year’s conference was the role of normal, beneficial gut flora in promoting healthy function with or without gut pathology—and this lecture was no exception. Both functional and pathologic bowel conditions are associated with decreased bacterial diversity.
Probiotics are preparations (or foods) containing beneficial live bacteria, such as Lactobacillus, Bifidobacterium, Acidophilus, and Saccharomyces boulardii. Recent meta-analyses and systematic reviews have found small overall beneficial effects with probiotics, compared with placebo. Prebiotics, in contrast, are nutritional supplements and foods that promote the growth of beneficial bacteria already in the colon; these include fiber, fiber supplements, and lactulose—oats are considered to be a naturally-occurring prebiotic. Studies supporting this practice are largely in vitro; little clinical evidence currently exists.
• Acupuncture: Two recent randomized studies suggest that acupuncture or sham acupuncture was superior to no-treatment in relieving IBS symptoms, but no significant differences were seen between acupuncture and sham—suggesting that perceived improvements were due to placebo effect.3,4
• Peppermint oil(Drug information on peppermint oil) has carminative (anti-flatulent) and anti-spasmodic properties, without anti-cholinergic side effects. Given poor quality control in supplements, Dr. Keshavarzian favors fresh mint tea prepared with hot water, and was open to the notion of using non-pharmacologically-labeled mint products like Altoids breath mints. Peppermint can exacerbate reflux and must be discontinued if not tolerated for that reason.
• Risks of ingested CAM. Herbal products are not under FDA jurisdiction, and can cause liver toxicity—herbal medicines are one of the leading causes of acute liver failure in the U.S. Quality control problems have included contamination with toxins, lead, and mercury. The PDR for Herbal Medicines is useful for assessing the biologic activity and toxicity profile of herbal preparations.
Dr. Keshavarzarian clearly views alternative therapies as part of the armamentarium in the treatment of IBS—skepticism is appropriate where evidence doesn’t exist—not as a blanket attitude. Primary care physicians would do well to adopt a similar view. Evidence-based approaches can and should be applied to these treatments.