Evidence-Based IBS Treatment Recommendations from ACG

A recent  American College of Gastroenterology Task Force conducted a systematic review (AC Ford et al. The American Journal of Gastroenterology 2018;113:1–18 ) to update management recommendations for irritable bowel syndrome -Link:

American College of Gastroenterology Monograph on Management of Irritable Bowel Syndrome

The highlights of this report are summarized at Gastroenterology & Hepatoloy: Highlights of the Updated Evidence-Based IBS Treatment Monograph

A few excerpts:

“There have been numerous studies performed on the roles of diet and dietary manipulation in IBS. Three fairly firm conclusions were made following the review of these studies: (1) the low–fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet seems to be effective for overall IBS symptom improvement; (2) a gluten-free diet is not effective for symptom improvement; and (3) conducting tests to detect various types of allergies or intolerances in order to base a diet on those results does not appear to be effective. Of these 3 conclusions, the most impressive data that came out of the research was the evidence for the low-FODMAP diet. Not only were there more studies on this diet, but the results were fairly consistent and favorable, at least for the short-term management of IBS.”

” We did not find evidence supporting the idea that prebiotics and synbiotics were effective in IBS management… In ­contrast, studies demonstrated that probiotics did improve global gastrointestinal symptoms, as well as the individual symptoms of bloating and flatulence in patients with IBS. However, determining which probiotic is best was difficult”

“Three prosecretory agents are available: linaclotide (Linzess, Allergan/Ironwood Pharmaceuticals), lubiprostone (Amitiza, Takeda), and plecanatide (Trulance, Synergy Pharmaceuticals), with plecanatide being the most recently approved agent. All 3 of these agents had convincing data to support their use in patients with constipation-predominant IBS

My take: In IBS patients, if dietary therapy is recommended, current evidence favors a low FODMAP diet rather than a gluten-free diet.

Related blog posts:

near Banff

Image above -Parker Ridge Trail

TARGET Study: Does Energy-Dense Nutrition Improve Outcomes in the Critically Ill

A recent double-blind randomized study (NEJM 2018; 379: 1823-44) examined the outcomes of 3957 adult patients undergoing mechanical ventilation who received either a 1.5 kcal formula or 1.0 kcal formula for provision of enteral nutrition.

Key Findings:

  • While the volume of formula was similar, the 1.5 kcal group received a mean of 1863 kcal/day compared to 1262 kcal/day for the 1.0 kcal group.
  • Yet, this did not translate into a survival benefit.  By day 90, 26.8% of the 1.5 kcal group had died compared with 25.7% of the 1.0 kcal group (RR 1.05, 95% CI 0.94-1.16, P=0.41)
  • Higher caloric delivery did not affect survival, receipt of organ support, duration of hospital stay, the incidence of infective complications or adverse events.
  • Regurgitation was more common in the 1.5 kcal group: 18.9% vs 15.7%, RR 1.20, 95% CI 1.05-1.38)
  • The 1.5 kcal group were more likely to receive promotility medications (47.4% vs 39.6%, RR 1.20)
  • The 1.5 kcal group were more likely to receive insulin (55.8% vs 49.0%, RR 1.14)

In their discussion, the authors note that only 2% of patients had a BMI less than 18.5; thus, their cohort is unable to determine whether these patients could benefit from increased calories.

My take (borrowed in part from authors): “Increasing energy intake with the administration of energy-dense enteral nutrition did not affect survival among critically ill adults.” These types of studies are important in challenging assumptions that meeting calorie needs (with enteral or parenteral nutrition) will improve outcomes in hospitalized patients–though, this may be true in some populations.

Related blog posts:

 

Interesting Study -Detrimental Dose-Response of Screen Time

In 1995, there was a Batman movie, “Batman Forever,” in which one of the central villains, the Riddler, places these brainwave devices over the TVs to gain control of Gotham.  The sad part, according to a recent study (J Zhao et al. J Pediatr 2018; 202; 157-62) is there is no need to add a brainwave device to a TV set.  Excessive screen time alone is quite detrimental.

In this cross-sectional survey in Shanghai with more than 20,000 children, the authors found the following:

  • Mean screen time for preschool children was 2.8 hrs per day.  78.6% exceeded 1 hour per day and 53% exceeded 2 hrs per day.
  • Every additional hour of screen time was associated with increased risk for poor psychosocial well-being; this effect on well-being had a number of mediators including reducing parent-child interaction as well as increased body mass index and reduced sleep duration.

My take: This study reinforces the consequences of excessive screen time  –now, the hard part — how to translate these findings into reduction in screen time.

Related blog posts:

 

 

Why Pureed Food Pouches Are Not a Good Idea for Young Children

A recent editorial (B Koletzko et al. JPGN 2018; 67: 561-3) explain why pureed fruit/food pouches can be detrimental for child health.  An easy-to-read editorial in NY Times discusses some of the same issues –Link: Rethinking Baby Food Pouches

Key points:

  • Pouches may interfere with learning to eat from a spoon.
  • Feeding infants “a variety of food textures and lumpy foods by spoon feeding and finger foods provides great opportunities for intensive reciprocal interaction between parent and infant”
  • These products generally have high energy density, high sugar content, and a very sweet taste and likely predispose towards bad food choices/selection as the child gets older.
  • Also, these food pouches may increase the risk of dental caries

Additional points from NY Times:

  • The popular pouches, introduced about a decade ago, now account for 25 percent of baby food sales in the United States, according to Nielsen’s Total Food View.
  • The features that make pouches so convenient, though — the smooth texture and squeeze packaging — have some experts concerned. They caution against relying on them too much, saying that they can be a gateway to bad long-term snacking habits and routine overeating
  • If given these pouches when irritable, children also run the risk of learning to associate sweet snacks with calming down, and to think of snacking in general as an activity to satisfy emotional rather than physiological needs.
  • “Feeding is truly a developmental process, just like learning to crawl, walk, run. We would never do anything to keep a child from crawling,” Ms. [Melanie] Potock [a feeding specialist] said. “Let’s not do anything that would stall them in the development of eating.”

Big Advance in Cystic Fibrosis –Who Will Benefit?

Recent studies point to huge advances in cystic fibrosis (CF) therapy. Though as noted in a previous blog (Why Do Canadians with Cystic Fibrosis Live Longer?), medical advances may have limited effect based on a lot of issues including access to care.

Despite that note of caution, it is hard not to be excited about a couple of recent publications which show that triple cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy has great potential to improve outcomes for CF patients.

  • JC Davies et al. NEJM 2018; 379: 1599-611.
  • D Keating et al. NEJM 2018; 379: 1612-20.
  • Editorial: F Holguin, 1671-2

Background: In the editorial, the pathophysiology of the defect of CF is discussed and how the newer medicines either act as a potentiator of the CFTR (ivacaftor) or as corrector (lumacaftor and tezacaftor).  Potentiators increase CFTR channel opening at the cell surface whereas correctors increase the amount of CFTR protein at the cell surface. One caveat has been that these therapies had not been proven effective, individually, for Phe508del CFTR mutation which occurs in “approximately two thirds of patients.”  Combination therapy has helped in most of this group but not in those with Phe508del-minimal function (MF).

The new studies examine triple therapy with the addition of two new-generation small molecule correctors: VX-445 and VX-659. These new correctors target different sites of the CFTR protein.

Key findings:

  • in the Davies (VX-659) trial, “4 weeks of triple therapy …increased the primary end point of predicted percentage of FEV1, in the Phe508del-MF and Phe508del-Phe508del groups by an averae of 13.3% and 9.7% respectively”
  • In the Keating (VX-445) trial, triple therapy “significantly increased FEV1 in patients with those genotypes by 13.8% and 11.0% respectively.”
  • Overall, triple therapy “improved the percentage of predicted FEV1 more than double-combination therapy” in patients with a Phe508del-Phe508del mutation.  And reported efficacy in the patients with Phe508del-MF CFTR mutation.
  • The majority of patients had at least one adverse event. 3 of the 122 in the VX-445 trial discontinue treatment due to severe adverse events.

My take: These reports “represent a major breakthrough…for improving health and possibly survival in all patients who carry the most common CFTR mutation.”  Long-term outcomes will need to be followed to confirm these findings.

Related blog posts:

This is Figure 2 from Davies study showing immunoblot findings, densitometry findings, and chloride transport in bronchial cells. The most robust responses were with triple therapy

 

#NASPGHAN18 Highlights (Part 2)

I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

My favorite slide from postgraduate course -Dr. Robert Kramer

Slides regarding the topic of Treat-toTarget Dr. Eric Benchimol:

Slides regarding GI symptoms and autism from Dr. Kara Margolis:

Slide regarding the frequency of bariatric surgery: Dr. Rohit Kohli:

Slides regarding intestinal failure population from Dr. Conrad Cole:

From Dr. Miranda van Tilburg regarding psychological therapies for functional GI disorders:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

#NASPGHAN18 Highlights and Tweets (part 1)

I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course

 

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.