A recent systematic review and network meta-analysis (CJ Black, et al. Clin Gastroenterol Hepatol 2020; 18: 1238-39) reviewed the relative efficacy of medications for irritable bowel syndrome with constipation. In total, the 14 trials randomized 9113 patients.
- All treatments were significantly more effective than placebo
- Linaclotide was ranked most effective; however, indirect comparison of active treatments revealed no significant differences between the individual drugs
According to a recent systematic review (Korterink JJ et al. J Pediatr 2015; 166: 424-31), “there is no evidence to support routine use of any pharmacologic therapy” for pediatric functional abdominal pain (FAP). How many pediatric gastroenterologists want to discuss this conclusion with their patients?
How did the authors reach their conclusion?
Design: The authors screened 557 articles and ultimately identified only four articles with a total of 6 studies met inclusion criteria which included the following:
- systemic review or randomized control trial
- children 4-18 years
- diagnosis of FAP established with well-defined criteria
- intervention was compared to placebo or alternative treatment
Results: All of the studies were reviewed –each received an overall quality rating by the authors as “very low.” The particular treatments included amitriptyline, peppermint oil, famotidine, miralax, tegaserod, and cyprohepatadine. The study with the most patients had only 90 patients and the longest treatment period was 4 weeks.
In the discussion, the authors make several key points:
- there is a lack of adequately powered, high-quality, placebo-controlled drug trials in children with FAP
- weak evidence was found in support of peppermint oil, cyproheptadine, and laxatives at reducing pain; amitriptyline and famotidine had weak evidence supporting some improvement in global symptoms or quality of life.
- problems with the studies: small sample sizes, poorly reported side effects, lack of follow-up, risk of bias
- “several nonpharmacologic therapies (e.g.. hypnotherapy and cognitive behavioral therapy) have shown their efficacy in treating children with” FAP…with success rates up to 85%. Moreover, these therapies are not hampered by severe side effects.”
Bottomline: Our office-based psychologist may be more helpful for our patients than all the medications combined.