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Oil in the Treatment of Irritable Bowel Effect of Fibre, Antispasmodics, And Downloaded from bmj.com on 17 November 2008 Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis Alexander C Ford, Nicholas J Talley, Brennan M R Spiegel, Amy E Foxx-Orenstein, Lawrence Schiller, Eamonn M M Quigley and Paul Moayyedi BMJ 2008;337;a2313 doi:10.1136/bmj.a2313 Updated information and services can be found at: http://bmj.com/cgi/content/full/337/nov13_2/a2313 These include: References This article cites 30 articles, 7 of which can be accessed free at: http://bmj.com/cgi/content/full/337/nov13_2/a2313#BIBL 1 online articles that cite this article can be accessed at: http://bmj.com/cgi/content/full/337/nov13_2/a2313#otherarticles Rapid responses You can respond to this article at: http://bmj.com/cgi/eletter-submit/337/nov13_2/a2313 Email alerting Receive free email alerts when new articles cite this article - sign up in the service box at the top left of the article Topic collections Articles on similar topics can be found in the following collections Neurogastroenterology (747 articles) Clinical trials (epidemiology) (3846 articles) Pain (neurology) (3079 articles) Internet (965 articles) Notes To order reprints follow the "Request Permissions" link in the navigation box To subscribe to BMJ go to: http://resources.bmj.com/bmj/subscribers Downloaded from bmj.com on 17 November 2008 RESEARCH Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis Alexander C Ford, clinical fellow,1 Nicholas J Talley, professor of medicine,2 Brennan M R Spiegel, assistant professorofmedicine,3 Amy EFoxx-Orenstein, associate professor of medicine,4 Lawrence Schiller, clinical professor,5 Eamonn M M Quigley, professor of medicine and human physiology,6 Paul Moayyedi, professor of gastroenterology1 1Gastroenterology Division, ABSTRACT known structural or anatomical explanation accounts McMaster University, Health Objective To determine the effect of fibre, for the pathophysiology of irritable bowel syndrome, Sciences Centre, 1200 Main Street West, Hamilton, ON, antispasmodics, and peppermint oil in the treatment of and the exact cause remains unknown, although L8N 3Z5, Canada irritable bowel syndrome. several mechanisms have been proposed. Altered 2Department of Medicine, Mayo Design Systematic review and meta-analysis of gastrointestinal motility may contribute to the change Clinic Florida, Jacksonville, FL, USA randomised controlled trials. in bowel habit reported by some patients,5 and a 3VA Greater Los Angeles Healthcare System; UCLA/VA Data sources Medline, Embase, and the Cochrane combination of smooth muscle spasm, visceral hyper- Center for Outcomes Research controlled trials register up to April 2008. sensitivity, and abnormalities of central pain proces- and Education, Los Angeles, CA, Review methods Randomised controlled trials comparing sing may explain the abdominal pain that is an essential USA fibre, antispasmodics, and peppermint oil with placebo or part of the symptom complex.67 4Division of Gastroenterology and Hepatology, Mayo Clinic no treatment in adults with irritable bowel syndrome were Irritable bowel syndrome is a chronic relapsing and Rochester, MN, USA eligible for inclusion. The minimum duration of therapy remitting condition,89 and a significant proportion of 5Digestive Health Associates of considered was one week, and studies had to report either patients will consult their general practitioner with Texas, Baylor University Medical a global assessment of cure or improvement in symptoms, symptoms.910 Current guidelines for the management Center, Dallas, TX, USA or cure of or improvement in abdominal pain, after of irritable bowel syndrome in the United Kingdom 6Department of Medicine, Cork University Hospital, Ireland treatment. A random effects model was used to pool data recommend that the diagnosis should be made on Correspondence to: A C Ford on symptoms, and the effect of therapy compared with clinical grounds alone, without the need for invasive [email protected] placebo or no treatment was reported as the relative risk investigations, unless alarm symptoms such as rectal (95% confidence interval) of symptoms persisting. 11 12 Cite this as: BMJ 2008;337:a2313 bleeding or weight loss are present. As a result doi:10.1136/bmj.a2313 Results 12 studies compared fibre with placebo or no general practitioners are increasingly responsible for treatment in 591 patients (relative risk of persistent the initial management of patients with irritable bowel symptoms 0.87, 95% confidence interval 0.76 to 1.00). syndrome and are expected to refer only a minority to This effect was limited to ispaghula (0.78, 0.63 to 0.96). secondary care. Twenty two trials compared antispasmodics with placebo If they are to fulfil this role effectively, general in 1778 patients (0.68, 0.57 to 0.81). Various practitioners need efficacious treatments that do not antispasmodics were studied, but otilonium (four trials, require monitoring and are cheap, safe, and readily 435 patients, relative risk of persistent symptoms 0.55, available. This is particularly relevant at the present 0.31 to 0.97) and hyoscine (three trials, 426 patients, time as newer and more expensive drugs have either 0.63, 0.51 to 0.78) showed consistent evidence of failed to show efficacy or been withdrawn from the efficacy. Four trials compared peppermint oil with placebo market owing to concerns about serious adverse in 392 patients (0.43, 0.32 to 0.59). events. Traditionally, people with irritable bowel Conclusion Fibre, antispasmodics, and peppermint oil syndrome were instructed to increase their daily intake were all more effective than placebo in the treatment of of dietary fibre, because of its potentially beneficial irritable bowel syndrome. effects on intestinal transit time.13 When this failed, various types of smooth muscle relaxants and anti- INTRODUCTION spasmodics were used in an attempt to ameliorate Irritable bowel syndrome is a functional gastro- symptoms, particularly pain and bloating.12 More intestinal disorder characterised by abdominal pain recently, peppermint oil, which has been shown to or discomfort and accompanied by a change in bowel have antispasmodic properties,14 has been available habit.1 The condition has a population prevalence of over the counter and has been used in the treatment of between 5% and 20% in community surveys.2-4 No irritable bowel syndrome. BMJ | ONLINE FIRST | bmj.com page 1 of 11 RESEARCH Downloaded from bmj.com on 17 November 2008 Whether any of these agents are effective in the treatment of irritable bowel syndrome is controversial. Studies identified in literature search (n=615) Results of randomised controlled trials are conflicting, Excluded (title and abstract and many have been underpowered to detect a revealed not appropriate) (n=514) difference between active treatment and control inter- vention. Systematic reviews have also come to different Studies retrieved for evaluation (n=101) conclusions about the efficacy of the three treatments in Excluded (n=66): irritable bowel syndrome.15-22 As a result confusion No placebo arm (n=33) exists as to the roles of these agents, with current Cross over study with no extractable data (n=8) Outcome of interest not reported (n=8) management guidelines for irritable bowel syndrome Duplicate publication (n=5) making varying recommendations.11 12 23 24 Not intervention of interest (n=4) Included patients with organic gastrointestinal We carried out a systematic review and meta- disease (n=2) analysis to determine the effect of fibre, anti- Included patients with other functional spasmodics, and peppermint oil in the treatment of gastrointestinal disorders, not extractable (n=2) Treatment duration less than 7 days (n=2) irritable bowel syndrome. Not randomised (n=1) Included patients treated for irritable bowel METHODS syndrome in remission before trial started (n=1) We searched the medical literature using Medline Studies eligible for inclusion (n=35): (1950 to April 2008), Embase (1980 to April 2008), and Antispasmodics (n=19) Fibre (n=9) the Cochrane controlled trials register (2007). We Antispasmodics or fibre (n=3) considered randomised controlled trials of adults Peppermint oil (n=4) (>16 years) with a diagnosis of irritable bowel ’ syndrome based on a clinician s opinion or that met Fig 1 | Flow diagram of studies in systematic review specific diagnostic criteria (Manning, Kruis score, Rome I, II, or III), combined with the results of “ ” “ ” “ investigations to exclude organic disease if trial hyoscine butyl bromide , butylscopolamine , pep- ” “ ” investigators thought this necessary. The studies had permint oil , and colpermin . to compare fibre, antispasmodics, and peppermint oil No language restrictions were applied. The lead with placebo or no treatment. Participants were reviewer evaluated the abstracts of papers identified by required to be followedup for at least one week, and the initial search for appropriateness to the study studies had to report either a global assessment of cure question. Potentially relevant papers were obtained or improvement of symptoms, or cure or improvement and evaluated in detail. Foreign language papers were of abdominal pain, after treatment. This was preferably translated when required. We hand searched abstract as reported by the patient, but could be documented by books of conference proceedings between 2001 and a doctor. If studies included patients with
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