Short Bowel Syndrome: Pharmacotherapy

Abstract

Short bowel syndrome (SBS) refers to a malabsorptive state resulting from loss of intestinal structure and/or function due to congenitally absent, extensively resected, and/or diseased bowel. SBS is typically defined by the presence of <200 cm of functional small intestine. Clinical implications of SBS are influenced by the extent and location of resected bowel, viable length and absorptive capacity of remnant bowel, and small intestinal continuity with the colon. Primary management objectives include establishing adequate fluid and electrolyte balance, promoting intestinal adaptation, and providing adequate hydration and nutritional (macro- and micronutrient) support. Pharmacotherapy is generally required in SBS and tailored to mitigate clinical symptoms. Unique facets of medication management in SBS include prescribing higher drug doses and/or alternate drug delivery routes to achieve adequate clinical response in the face of malabsorption. Medication efficacy is further influenced by available absorptive surface area, remnant anatomy, intestinal transit and mucosal contact time, and acid/alkaline environment, among others. The etiology of diarrhea in SBS may be complex and multifactorial; targeted therapeutic strategies addressing rapid intestinal transit, gastric acid hypersecretion, fat malabsorption, and small intestinal bacterial overgrowth must be considered. Two pharmacologic options available for short-term SBS treatment in patients receiving parenteral nutrition and/or intravenous support are: Somatropin (a recombinant form of human growth hormone) and Teduglutide (a glucagon-like peptide-2 analog). These intestinotrophic hormones are progressive pharmacologic extensions of tailored fluid, nutritional, and standard medication management strategies in SBS. Overall, a comprehensive and multidisciplinary treatment approach is paramount, and various regimens may be required. Medication optimization with frequent reassessments over time can moderate clinical consequences and maximize intestinal rehabilitation potential. Surgical management options may be considered in select SBS cases and are briefly discussed.