The challenges of implementing evidence-based therapy for irritable bowel syndrome in Asia.

Abstract

Disorders of gut-brain interaction (DGBI), previously known as functional gastrointestinal disorders (FGIDs), affect more than 40% of the population worldwide.1 Irritable bowel syndrome (IBS), one of the most prevalent FGIDs, was previously thought to be less common in Asia compared to the West.2 With urbanization, the prevalence of IBS in Asia has increased, with a prevalence rate of 1.5 to 4.1% with the latest Rome IV criteria.1 Studies in primary and secondary care in Asia have shown that IBS is common among adults who consult for their symptoms.3 Although it does not affect mortality, IBS in Asia has been shown to have a significant impact on patients' quality of life and also increases the healthcare burden.1, 3 The impact of IBS can be reduced by implementing appropriate, evidence-based therapy in this condition. The latest British Society of Gastroenterology guidelines and the recent Asian Consensus on IBS advocate the establishment of an effective doctor-patient relationship as the key to a successful management of IBS.4, 5 Once this relationship is established, subsequent treatment is generally directed toward predominant symptoms experienced by IBS patients. Anti-spasmodics are recommended for abdominal pain and neuromodulating agents are reserved as second line therapy. In a recent network meta-analysis of 51 randomized controlled trials, peppermint oil was ranked first for efficacy in improving global symptoms, while tricyclic antidepressants were ranked first for efficacy in relieving abdominal pain.4 Constipation is mainly treated with laxatives, while secretagogues or 5-hydroxytryptamine (5-HT4) agonists are considered as second line. For diarrhea symptoms in IBS, loperamide is recommended as first line, while rifaximin and 5-HT3 receptor antagonists can be used as second line agents. Nonpharmacological therapy, including dietary modulation and psychotherapy have also been recommended either as mainstay or adjunct management.4, 5 A low fermentable oligo-saccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet has been ranked as the most effective dietary treatment for IBS in a network meta-analysis. This therapy has been shown to be effective in treating global symptoms/ abdominal pain, particularly when supervised by a trained dietitian.4 In this issue, Quach et al. report on the epidemiology and the challenges of managing IBS in Vietnam. Common pharmacological options for IBS were widely used in the country, however, several second line medications, including secretagogues (linaclotide, lubiprostone) and 5-HT3 receptor antagonists (alosetron, ramosetron) were not available. A low FODMAP dietary management and psychotherapy applications in Vietnam were also reported to be limited for various reasons.6 In a previous survey of IBS management among physicians in emerging economies in Asia, second line medication such as lubiprostone was not often prescribed,7 while linaclotide had not been approved for use by regulatory health authorities.2 In a report from the United States, anxiolytics and antidepressants were found to be utilized in 55 and 61% of IBS patients, respectively. In contrast, a survey of gastroenterology specialist clinics from 11 Asian cities showed that only 20% of IBS patients were prescribed with psychotropic agents.2 Meanwhile, another survey from Asia found that only 26% of gastroenterologists would use psychotherapy as part of the treatment of IBS, possibly due to a lack of trained psychologists.8 Despite the widespread acceptance of a low FODMAP diet across Western countries, the application of the diet has more uncertainties in Asia due to several factors: (i) A limited database of FODMAP contents in some Asian meals, (ii) the limited knowledge of clinicians regarding diet therapy and (iii) a paucity of dietitians in the region.9 Furthermore, IBS patients in certain parts of Asia tend to seek healthcare consultations from traditional complementary medicine (TCM) rather than modern medical practitioners, which may limit the improvement of symptoms and quality of life.2 The management of IBS patients in Asia is still far from perfect. The Rome Foundation Asian Working Team reported that up to half of IBS patients were dissatisfied with the treatment in gastroenterology outpatient clinics.10 With limited resources, countries in Asia, especially those from less affluent countries have many challenges in implementing evidence-based therapy for IBS effectively. While the newer pharmacological agents for IBS may be considered expensive, nonpharmacological therapy such as dietary and psychological management is not. There is an urgent need to change the attitudes of physicians (and patients) toward psychotropic treatment and diet-based therapy. Acceptance of these treatments will increase the demand for more professionals (psychologists and dietitians) to be trained and provide these relatively inexpensive services for IBS patients in Asia.