#229 Antispasmodics and peppermint oil: Old news or a breath of fresh air in managing Irritable Bowel Syndrome
CLINICAL QUESTION
Are antispasmodics (including peppermint oil) effective in treating irritable bowel syndrome symptoms?
BOTTOM LINE
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
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.
- 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.
- "Slight" or "significant" symptom improvement: hyoscine + acetaminophen=81%, hyoscine=76%, acetaminophen=72%, placebo=64%;
- 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.
- 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
- Cost varies significantly
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