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#229 Antispasmodics and peppermint oil: Old news or a breath of fresh air in managing Irritable Bowel Syndrome


CLINICAL QUESTION
QUESTION CLINIQUE
Are antispasmodics (including peppermint oil) effective in treating irritable bowel syndrome symptoms?


BOTTOM LINE
RÉSULTAT FINAL
Approximately 60% of patients report overall symptom or abdominal pain "improvement" on antispasmodics (including peppermint oil), compared to ~30-50% on placebo, with numbers needs to treat of 3-8.  Compared to placebo, adverse events occur for an additional 1 in 20 with antispasmodics and 1 in 11 on peppermint oil.



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EVIDENCE
DONNÉES PROBANTES
3 Systematic Reviews:
  • 29 randomized controlled trials (RCTs), 2333 patients, various antispasmodics, including peppermint oil.1 Patient reported outcomes after 1 week to 6 months:
    • Overall "symptom improvement": 57% versus 39% placebo; number needed to treat (NNT)=6.
    • Abdominal pain "improvement": 58% versus 46% placebo; NNT=8
  • Older systematic review (13 RCTs, 1379 patients). Outcomes at 2 weeks-6 months similar.2 Adverse events (dry mouth, dizziness, blurred vision reported):
    • 14% versus 9% placebo; number needed to harm (NNH)=20.
  • Systematic review of peppermint oil alone (9 RCTs, 726 patients, 2-12 weeks duration).3
    • Overall "symptom improvement": 69 versus 31% placebo; NNT=3.
    • Abdominal pain "improvement": 57% versus 27% placebo; NNT=4.
    • Overall adverse events (including heartburn, dry mouth, peppermint smell/taste):
      • 22% versus 13% placebo; NNH=11.
Newest RCTs:
  • 712 patients randomized to hyoscine, hyoscine + acetaminophen, acetaminophen, or placebo for four weeks.4 Paper translated by TFP authors.
    • "Slight" or "significant" symptom improvement: hyoscine + acetaminophen=81%, hyoscine=76%, acetaminophen=72%, placebo=64%;
      • Hyoscine groups statistically better than placebo.
    • Adverse events: 5% overall.
  • 427 patients given pinaverium 50mg or placebo TID.5 After 4 weeks:
    • >30% improvement in abdominal pain: 62% versus 30% placebo; NNT=3.
  • 72 patients given peppermint oil tablets or placebo.6 After 4 weeks:
    • Mean reduction 4-point symptom score: ~1.2 peppermint oil versus 0.7 placebo.
Limitations: small studies,1,2 short durations,1 multiple/incomplete outcomes reported1,4, conflicts of interest/industry funding3,6, use of non-validated scales.6 Context:
  • Large placebo response often seen in IBS studies.7
  • Guidelines recommend considering antispasmodics8,9 or peppermint oil8 in IBS patients.
  • Antispasmodics in Canada include hyoscine, pinaverium, trimebutine, dicycloverine, peppermint oil.
    • Cost varies significantly
      • Peppermint oil ranges ~$60 to $360 for 3 months.10


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Author(s)
Auteur(s)
  • Amol Bhargava MD MSc
  • Michael R Kolber MD CCFP MSc

1. Ruepert L, Quartero AO, de Wit NJ, et al. Cochrane Database Syst Rev. 2011; 8:CD003460.

2. Ford AC, Talley NJ, Spiegel BMR, et al. BMJ. 2008; 337:a2313.

3. Khanna R, MacDonald JK, Levesque BG. J Clin Gastroenterol. 2014; 48(6): 505-12.

4. Schafer VE, Ewe K. Fortschr. Med. 1990; 25: 488-92.

5. Zhang L, Lai Y, Lu W, et al. Clin Gastroenterol Hepatol. 2015; 13:1285-92.

6. Cash BD, Epstein MS, Shah SM. Dig Dis Sci. 2016; 61:560-71.

7. Kaptchuk TJ, Friedlander E, Kelley JM, et al. PLOS One. 2010; 5(12):e15591.

8. Ford AC, Moayyedi P, Lacy BE, et al. Am J Gastroenterol. 2014; 109:S2 - S26

9. National Institute for Health and Care Excellence (NICE). 2017. Irritable bowel syndrome in adults: diagnosis and management. CG61.

10. Walmart.ca. 2018. https://www.walmart.ca/en/ip/ibgard-for-irritable-bowel-syndrome/6000196689003. Accessed Sept 3, 2018.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.