TITLE: Trimebutine Maleate and Pinaverium Bromide for Irritable Bowel Syndrome: A Review of the Clinical Effectiveness, Safety and Guidelines DATE: 30 November 2015 CONTEXT AND POLICY ISSUES Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder characterized by abdominal pain or discomfort and altered bowel movement consistency and frequency resulting in constipation or diarrhea.1,2 It is a functional disorder and not an organic disease.2 According to the Rome III diagnostic criteria, IBS is defined as recurrent abdominal pain or discomfort for at least three days per month in the last three months and with two or more of the following: improvement with defecation, onset associated with a change in frequency of stool, or onset associated with a change in form (appearance) of stool.2,3 There are three main subtypes of IBS: IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), and mixed IBS (IBS-M).2 Hard or lumpy stool with ≥25% of bowel movements and loose or watery stool with < 25% of bowel movements is indicative of IBS-C. Loose or watery stool with ≥25% of bowel movements and hard or lumpy stool with < 25% of bowel movements is indicative of IBS-D. Hard or lumpy stool with ≥25% of bowel movements and loose or watery stool with ≥ 25% of bowel movements is indicative IBS-M. 2 The reported prevalence estimates of IBS vary widely. Some of this variation may result from differences in the clinical setting and the criteria used for diagnosis.1 There is no gold standard for diagnosing IBS.1 Criteria for diagnosing IBS include Kruis scoring system, Manning criteria and Rome I, II, and III criteria.1 Often, in clinical practice, diagnosis of IBS is based on typical history, normal physical examination and absence of any alarming symptoms such as gastrointestinal bleeding or an abdominal mass.1 The prevalence rate of IBS in Canada was reported as 12.1% according to a physician-led postal survey and 25.2% from a study investigating the health related quality of life of IBS patients.4 The Canadian prevalence rates for IBS have also reported as ranging between 6.2% and 25.2%.4 IBS is more prevalent in females than in males.1 IBS impacts one’s quality of life (QoL). It has been reported that the QoL of patients with IBS is lower than the QoL of patients with diabetes mellitus, dialysis dependent end stage renal disease, or gastroesophageal reflux.5 IBS has a substantial impact on health care resource utilization. IBS can also result in absence from work and hence productivity loss. The pathophysiology of IBS is unclear.6,7 Some of the suggested mechanisms and factors, Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic review s. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts w ithin the time allow ed. Rapid responses should be considered along w ith other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for w hich little information can be found, but w hich may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material and may contain material in w hich a third party ow ns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a w eb site, redistributed by email or stored on an electronic system w ithout the prior w ritten permission of CADTH or applicable copyright ow ner. Links: This report may contain links to other information available on the w ebsites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions. include visceral hypersensitivity, altered colonic motility, abnormal colonic flora, inflammation, stress, psychological and genetic factors.1,7 Although, not all individuals with IBS seek medical help, patients with IBS constitute a significant proportion of outpatient visits to gastroenterologists and other health care providers.2 Non-pharmacological agents (such as dietary fiber, probiotics, and acupuncture),2,8 and pharmacological agents (such as antidepressants and antispasmodics)1,2 have been used for the management of IBS. Two antispasmodics, trimebutine maleate and pinaverium bromide are the focus of this report. Antispasmodics are believed to improve bowel habits by increasing colonic transit time thereby decreasing stool passage frequency as well as reducing pain by inhibiting contractile pathways in the gut.7 The purpose of this report is to review the clinical effectiveness and safety of trimebutine maleate and pinaverium bromide for the treatment of adult and adolescent patients with IBS and to review the evidence-based guidelines on the use of these two agents for IBS. RESEARCH QUESTIONS 1. What is the clinical effectiveness and safety of trimebutine maleate for the treatment of patients with irritable bowel syndrome? 2. What is the clinical effectiveness and safety of pinaverium bromide for the treatment of patients with irritable bowel syndrome? 3. What are the evidence-based guidelines for the use of trimebutine maleate and pinaverium bromide for the treatment of irritable bowel syndrome? KEY FINDINGS Evidence suggests that compared with placebo there may be improvement in abdominal pain with trimebutine or pinaverium treatment for adult patients with irritable bowel syndrome (IBS), however results were not always statistically significant. Findings from single RCTs suggest improvement in stool consistency and frequency with trimebutine or pinaverium treatment. Adverse effects with trimebutine or pinavarium appeared to be few, however not many studies reported on adverse effects. No evidence-based guidelines were identified for the use of trimebutine and pinaverium for the treatment of irritable bowel syndrome. METHODS Literature Search Methods A limited literature search was conducted on key resources including Medline, Embase, PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2010 and October 21, 2015. Rapid Response reports are organized so that the evidence for each research question is presented separately. Trimebutine and Pinaverium for IBS 2 Selection Criteria and Methods One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1. Table 1: Selection Criteria Population Adults and adolescents with irritable bowel syndrome Intervention Trimebutine maleate (Modulon) or pinaverium bromide (Dicetel) Comparator Any active comparator, placebo or no comparator Outcomes Clinical effectiveness (e.g. relief of IBS symptoms, reduced abdominal pain, reduced bowel disturbances, decreased intestinal discomfort), safety, evidence-based guidelines. Study Designs Health technology assessments (HTA), systematic reviews (SR), meta-analyses (MA), randomized controlled trials (RCT), observational studies, and evidence-based guidelines Exclusion Criteria Articles were excluded if they did not meet the selection criteria outlined in Table 1, they were duplicate publications, or were published prior to 2010. Articles on multiple drugs that did not present data separately for trimebutine or pinaverium were excluded. Articles on gastrointestinal disorders that did not present data for IBS separately were excluded. Articles comparing trimebutine or pinaverium with alternative or complementary medicine such as acupuncture or traditional Chinese spinal orthopedic manipulation were excluded. Critical Appraisal of Individual Studies The included systematic reviews were critically appraised using AMSTAR,9 and randomized controlled trials and observational studies were critically appraised using the Downs and Black checklist.10 Summary scores were not calculated for the included studies; rather, a review of the strengths and limitations of each included study were described narratively. SUMMARY OF EVIDENCE Quantity of Research Available A total of 58 citations were identified in the literature search. Following screening of titles and abstracts, 45 citations were excluded and 13 potentially relevant reports from the electronic search were retrieved for full-text review. One potentially relevant publication was