INTERVENTIONS FOR THE TREATMENT OF IRRITABLE BOWEL SYNDROME: A REVIEW OF COCHRANE SYSTEMATIC REVIEWS

SCACIOTA, Ana Carolina Lemes; MATOS, Delcio; ROSA, Manuelle Mastrorocco Brand; COLOVATI, Mileny Esbravatti Stephano; BELLOTTO, Elisa Fatima Benavent Caldas; MARTIMBIANCO, Ana Luiza Cabrera

doi:10.1590/S0004-2803.202100000-20

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REVIEW • Arq. Gastroenterol. 58 (01) • Jan-Mar 2021 • https://doi.org/10.1590/S0004-2803.202100000-20 copy

INTERVENTIONS FOR THE TREATMENT OF IRRITABLE BOWEL SYNDROME: A REVIEW OF COCHRANE SYSTEMATIC REVIEWS

Intervenções para o tratamento da síndrome do intestino irritável: revisão de revisões sistemáticas Cochrane

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Irritable bowel syndrome (IBS) is a complex gastrointestinal disorder, whose understanding is relatively uncertain, and the treatment guidance decision still represents a challenge.

OBJECTIVE:

To identify and critically appraise systematic reviews (SRs) published in the Cochrane Database of SRs (CDSR) on the effects of interventions (pharmacological and non-pharmacological) for the treatment of IBS.

METHODS:

The search was conducted at the Cochrane Library in May 2020. The methodological quality of the SRs was evaluated by the AMSTAR-2 tool.

RESULTS:

Eight SRs with moderate to high quality were included, which addressed the treatments: (a) pharmacological: volume agents, antispasmodics, antidepressants and tegaserod; and (b) non-pharmacological: homeopathy, acupuncture, phytotherapy, biofeedback, psychological interventions and hypnotherapy. The results were favorable to antispasmodic drugs and antidepressants regarding the improvement of clinical symptoms. There was no difference between volume agents or tegaserod when compared to placebo. Acupuncture and homeopathy showed a little improvement in symptoms compared to placebo, but the certainty of this evidence was considered low to very low. Psychological interventions seem to improve the overall assessment of the patient and relief symptoms such as abdominal pain. However, there was no long-term follow-up of these patients. The results of the other treatments were considered uncertain due to the high risk of bias.

CONCLUSION:

Considering the low quality of the studies included in the SRs, pharmacological treatment with antispasmodics and antidepressants seems to be beneficial for patients with IBS. Among non-pharmacological interventions, psychological interventions seem to be beneficial. However, further clinical trials are recommended with greater methodological rigor to prove these findings.

HEADINGS:
Irritable bowel syndrome; Systematic review; Evidence-based medicine

AMSTAR-2	Systematic reviews included
	Ruepert 2011¹³13. Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JWM. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD003460.	Evans 2007¹⁴14. Evans BW, Clark WK, Moore DJ, Whorwell PJ. Tegaserod for the treatment of irritable bowel syndrome and chronic constipation. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD003960.	Manheimer 2012¹⁵15. Manheimer E, Cheng K, Wieland LS, Min LS, Shen X, Berman BM, Lao L. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD005111.	Peckham 2019¹⁶16. Peckham EJ, Cooper K, Roberts ER, Agrawal A, Brabyn S, Tew G. Homeopathy for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2019, Issue 9. Art. No.: CD009710.	Goldenberg 2019¹⁷17. Goldenberg JZ, Brignall M, Hamilton M, Beardsley J, Batson RD, Hawrelak J, Lichtenstein B, Johnston BC. Biofeedback for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD012530.	Liu 2006¹⁸18. Liu JP, Yang M, Liu Y, Wei ML, Grimsgaard S. Herbal medicines for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004116.	Zijdenbos 2009¹⁹19. Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO. Psychological treatments for the management of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006442.	Webb 2007²⁰20. Webb AN, Kukuruzovic R, Catto-Smith AG, Sawyer SM. Hypnotherapy for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005110.
1. Search question (PICO)	Y	Y	Y	Y	Y	Y	Y	Y
2. Study planning (protocol)	Y	Y	Y	Y	Y	Y	Y	Y
3. Justification for the selection of the study design	Y	Y	Y	Y	Y	Y	Y	Y
4. Search strategies	Y	Y	Y	Y	Y	Y	Y	Y
5. Study selection in duplicate	Y	Y	Y	Y	Y	Y	Y	Y
6. Data extraction in duplicate	Y	Y	Y	Y	Y	Y	Y	Y
7. Report of excluded studies	Y	Y	Y	Y	Y	Y	Y	Y
8. Characteristics of the studies included	Y	Y	Y	Y	Y	Y	Y	Y
9. Risk of bias assessment	Y	Y	Y	Y	Y	Y	Y	Y
10. Reporting of the sources of funding for the studies	N	Y	Y	Y	Y	Y	N	N
11. Appropriate statistical methods for meta-analysis	Y	Y	Y	Y	Y	NA	Y	Y
12. Assessment of the impact of the risk of bias in meta-analyses	Y	Y	Y	Y	Y	NA	Y	Y
13. Risk of bias in interpretation and results	Y	Y	Y	Y	Y	Y	Y	Y
14. Discussion and explanation of heterogeneity	Y	Y	Y	Y	Y	Y	Y	Y
15. Investigation of publication bias	Y	Y	Y	Y	Y	NA	Y	Y
16. Report of conflict of interest of the authors of the review	Y	Y	Y	Y	Y	Y	Y	Y
Total (quality)	High	High	High	High	High	Moderate	High	High

Interventions compared to placebo	Outcomes [95% CI]
	Abdominal pain	Overall assessment	Symptom improvement
Bulking agents	There was no difference	There was no difference	IBS score: there was no difference
	SMD 0.03 [-0.34 to 0.40]	RR 1.10 [0.91 to 1.33]	SMD -0.00 [-0.43 to 0.43]
	4 RCTs, n=186	11 RCTs, n=565	3 RCTs, n=126
Antispasmodic	Improvement in favor of intervention	Improvement in favor of intervention	IBS score: improvement in favor of intervention
	RR 1.32 [1.12 to 1.55]	RR 1.49 [1.25 to 1.77]	RR 1.86 [1.26 to 2.76]
	13 RCTs, n=1392	22 RCTs, n=1983	4 RCTs, n=586
Antidepressants	Improvement in favor of intervention	Improvement in favor of intervention	IBS score: improvement in favor of intervention
	RR 1.49 [1.05 to 2.12]	RR 1.57 [1.23 to 2.0]	RR 1.99 [1.32 to 2.99]
	8 RCTs, n=517	11 RCTs, n=750	3 RCTs, n=159
Tegaserode 4 mg	There was no difference	Improvement in favor of intervention	Bowel habits: improvement in favor of intervention
	RR 1.10 [0.82 to 1.49]	RR 1.15 [1.02 to 1.31]	RR 1.21 [1.02 to 1.43]
	3 RCTs, n=1675	3 RCTs, n=1675	3 RCTs, n=1675
Tegaserode 12 mg	There was no difference	Improvement in favor of intervention	Bowel habits: there was no difference
	RR 1.16 [0.89 to 1.51]	RR 1.19 [1.09 to 1.29]	RR 1.10 [0.93 to 1.31]
	3 RCTs, n=1675	4 RCTs, n=3194	3 RCTs, n=1675

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[1] Corresponding author: Ana Luiza Cabrera Martimbianco. E-mail: analuizacabrera@hotmail.com