Harvard Medical School: Treatment options for irritable bowel syndrome

In this issue of HEALTHbeat:
• Treatment options for irritable bowel syndrome
• Selenium and vitamin E for prostate cancer

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March 17, 2009

Dear HEALTHbeat subscriber,

Who hasn’t had the occasional intestinal complaint? Maybe you’ve been eating unfamiliar food, have a stomach bug, or are under stress. But for as many as one in five Americans, gastrointestinal discomfort in the form of irritable bowel syndrome (IBS) is a chronic problem that can take a significant toll on quality of life—from the need for inconvenient trips to the bathroom to disabling abdominal pain. This issue of HEALTHbeat provides the latest IBS treatment guidelines from the American College of Gastroenterology. Also, Dr. Harvey Simon, editor in chief of the Harvard Men’s Health Watch, discusses the latest recommendations on selenium, vitamin E, and prostate cancer.

Wishing you good health,

Nancy Ferrari
Managing Editor
Harvard Health Publications
HEALTHbeat@hms.harvard.edu



	Treatment options for irritable bowel syndrome [READ]



	Notable from Harvard Medical School: * The Sensitive Gut * Prostate Disease [READ]



	Selenium and vitamin E for prostate cancer [READ]

From Harvard Medical School
The Sensitive Gut

Have you ever wondered why your stomach feels queasy when you’re nervous or why emotions sometimes roil your intestines? If so, you are experiencing the symptoms of the gut-brain connection. The Sensitive Gut describes the many gastrointestinal conditions that are caused or at least exacerbated by stress, emotion, anxiety and other brain-to-gut messages.

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$1\$ Treatment options for irritable bowel syndrome

Women are twice as likely as men to suffer from irritable bowel syndrome (IBS), a chronic condition characterized by recurrent bouts of constipation, diarrhea, or both, as well as abdominal pain, bloating, and gas. It’s the most common diagnosis made by gastroenterologists and second only to colds as a cause for absence from work.

IBS is a functional disorder, which means that as far as we know, it is not caused by any underlying disease or structural abnormality. Experts believe that IBS involves various, often interacting, factors — infection, faulty brain-gut communication, heightened pain sensitivity, hormones, allergies, and emotional stress.

Fortunately, IBS doesn’t increase the risk for more serious conditions, such as ulcerative colitis or colon cancer. But it can be hard to live with. Symptoms range from annoying to debilitating.

What should you do if you think you or a family member is suffering from IBS?

In late 2008, the American College of Gastroenterology released new recommendations regarding the management of IBS. For example, extensive testing (complete blood count, thyroid function test, stool testing for parasites, and abdominal imaging) is unnecessary for people with typical IBS symptoms who have no family history of colon cancer, inflammatory bowel disease, or celiac disease — and no “alarm symptoms,” including rectal bleeding, weight loss, or iron-deficiency anemia. People with diarrhea-predominant or mixed types of IBS should have a blood test for celiac disease and may want to consider lactose breath testing if symptoms of lactose intolerance remain a problem despite dietary changes.

The guidelines also simplify the language used to describe IBS. The disorder is now defined simply as “abdominal pain or discomfort that occurs in association with altered bowel habits over a period of at least three months.”
The panel reviewed 300 studies on the natural course, diagnosis, and treatment of IBS and developed a series of recommendations.

Treatment	Recommendations
Antibiotics	Short-term use of rifaximin (Xifaxan), a nonabsorbable antibiotic (one that stays in the gut), helps reduce overall symptoms, especially bloating. Its long-term safety and effectiveness are uncertain, and it is not yet approved for IBS. Rifaximin is approved for traveler’s diarrhea. Early trials of the drug in IBS patients evaluated higher doses given for longer periods. Note: Rifaximin is very expensive. Other antibiotics might work in some cases at a fraction of the cost.
Bulking agents and fiber	Bulking agents that contain psyllium — for example, Metamucil, Fiberall, Hydrocil, and Konsyl — improve overall symptoms, but neither wheat bran nor corn bran is better than a placebo in managing IBS.
FDA-approved IBS drugs	The newest IBS drug, lubiprostone (Amitiza), is effective in relieving overall symptoms in women with constipation-predominant IBS. It should not be taken by women who are or could become pregnant. Alosetron (Lotronex) is effective in relieving symptoms of women with diarrhea-predominant IBS, but its availability and use are limited because it’s been linked to severe constipation and ischemic colitis (reduced blood flow to the intestine). Tegaserod (Zelnorm) helps relieve overall symptoms of women with constipation-predominant IBS — and in both men and women with mixed IBS. It was briefly removed from the market in 2007 because of a slight increase in cardiovascular risk and is now available only to women under age 55 who are in critical need of it and have no known heart problems.
Antispasmodics	In the United States, the antispasmodics dicyclomine (Bentyl) and hyoscyamine (Levsin) are often prescribed for IBS pain. Peppermint oil may also have an antispasmodic effect, however people with gastroesophageal reflux disease should avoid peppermint oil because it can cause heartburn.
Psychological therapies	Twenty randomized controlled trials have shown that psychological therapies, including cognitive therapy, dynamic psychotherapy, and hypnotherapy — but not relaxation therapy — are more effective than usual care in relieving overall symptoms.
Probiotics	Research is difficult because there are many strains of probiotics, and preparations and doses vary. Lactobacilli alone apparently don’t relieve IBS symptoms, but certain combination products help. Bifidobacteria, another kind of intestinal flora, may also be effective.
Antidepressants	Tricyclic antidepressants and selective serotonin reuptake inhibitors are effective in relieving overall symptoms and reducing abdominal pain, but not much is known about their safety and tolerability in people with IBS. Note: Antidepressants used for treating IBS are prescribed at doses lower than those used to treat depression.

Because there is no cure for IBS, treatment aims to control individual symptoms. As a result, the management of IBS requires a great amount of understanding between doctor and patient. People suffering from IBS need to educate themselves about the condition and gather as much information as possible from their doctors so they can learn to manage the syndrome and regain control over their lives.

For more information about irritable bowel syndrome, order our Special Health Report, The Sensitive Gut, at www.health.harvard.edu/SG.



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For more information about irritable bowel syndrome, order our Special Health Report, The Sensitive Gut.

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$2\$ Notable from Harvard Medical School

** The Sensitive Gut

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** Prostate Disease

For a small gland, the prostate can cause big problems. More than half of men in their sixties have enlarged prostates. Prostate cancer is second only to lung cancer as a fatal malignancy. And prostatitis is a condition that affects even young men. This report describes the causes and treatment of prostate diseases and provides practical advice for coping with troubling side effects, including incontinence and erectile dysfunction.

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$3\$ Selenium and vitamin E for prostate cancer

Q: I have been taking selenium in the hope that it would prevent me from getting prostate cancer. But I heard on the radio that the National Cancer Institute is advising men to stop taking selenium. Should I stop it?

A. Many men shared the hope that selenium might reduce the risk of prostate cancer. The optimism stemmed from a 1996 report from the Nutritional Prevention of Cancer Trial, which found that 200 micrograms (mcg) of selenium a day reduced the risk of prostate cancer by a startling 63%. A series of observational studies followed; although the results were mixed, many suggested that selenium might help.

When results are mixed or surprising, the next step is a careful randomized clinical trial. Beginning in 2001, the National Cancer Institute recruited over 35,000 men age 50 and above to test the effects of selenium and vitamin E, which had also shown mixed results against prostate cancer. The men were randomly assigned to take 200 mcg of selenium, 400 international units (IU) of vitamin E, both selenium and vitamin E, or a placebo every day.

The Selenium and Vitamin E Cancer Prevention Trial (SELECT) was conducted at over 400 research centers in the U.S., Puerto Rico, and Canada at a cost of over $114 million. Results were not expected until 2011, but in late 2008 an independent monitoring group halted the trial because neither supplement was beneficial. In fact, there was a hint that selenium might be responsible for a slight increase in diabetes and that vitamin E might be linked to a slight increase in prostate cancer.

SELECT was expensive, and it produced disappointingly negative results. Still, the trial was very important and very productive. It tells us definitively that neither selenium nor vitamin E has a role in preventing prostate cancer. Scientists will continue to monitor the volunteers for at least three years to conduct additional studies on prostate cancer and other diseases of male aging.

Like the SELECT volunteers, you should stop your supplements. Unfortunately, selenium and vitamin E have joined the ever-lengthening list of supplements that have failed careful, objective scientific testing.

— Harvey B. Simon, M.D.
Editor, Harvard Men’s Health Watch

This Question and Answer first appeared in the February 2009Harvard Men’s Health Watch, available at www.health.harvard.edu/mens.



FOR FURTHER READING

For more information on prostate health, order our Special Health Report, Prostate Disease.

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Harvard Medical School publishes authoritative Special Health Reports on a wide range of topics. Each report delivers practical information on diagnosis, treatment, and prevention of major health concerns in clear, easy-to-understand language. For more information on a specific topic, click the appropriate link below: Alzheimer’s, Arthritis, Bladder, Cholesterol, Depression, Diabetes, Digestion, Energy, Exercise, Eye Disease, Headache, Heart Disease, High Blood Pressure, Memory, Menopause, Prostate, Sexuality, Sleep, Stroke, Vitamins

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Harvard Medical School offers special reports on over 50 health topics. Visit our Web site at http://www.health.harvard.edu to find reports of interest to you and your family. Copyright 2009 by Harvard University.



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