​After a lapse of 5 years, the consensus opinion of the experts on irritable bowel syndrome in China has been updated, and the main points of the update have been analyzed in one article!

It is only for medical professionals to read and refer to the changes in diagnosis and treatment of IBS from the latest consensus in China
.

Irritable bowel syndrome (IBS) is a common clinical functional gastrointestinal disease with a high population prevalence and an increasing trend [1]
.

Abdominal pain, constipation and other uncomfortable symptoms often make IBS patients accompanied by depression, anxiety and somatic disorder, which greatly affects the quality of life and brings a heavy economic burden to society, families and individuals [2]
.

Since 2015, after a lapse of 5 years, the Gastrointestinal Functional Diseases Collaboration Group of the Gastroenterology Branch of the Chinese Medical Association once again issued the "Chinese Expert Consensus of Irritable Bowel Syndrome" [3] to better guide the clinical practice of IBS in China Diagnosis and treatment
.

Part 1 analyzes the main points of the new consensus from 4 aspects.
The new consensus defines the definition and epidemiology, etiology, and pathogenesis of IBS based on the 2015 China IBS expert consensus based on the 2016 Rome IV standard and national conditions.
The four aspects of diagnosis and treatment have been updated, and the interpretations are as follows: 1.
The new consensus on definition and epidemiology The definition of IBS mainly covers symptoms, the correlation with defecation, and whether to exclude organic diseases
.

In terms of symptoms, the new consensus retains "abdominal pain, bloating, and abdominal discomfort" as the main symptoms of IBS in combination with the condition of Chinese patients, and deletes the description of "more improvement in symptoms after defecation" in terms of the relevance of defecation
.

The prevalence of IBS can vary greatly due to the choice of survey subjects, survey methods and diagnostic criteria
.

In view of the differences in different regions, populations and diagnostic criteria, the new consensus has updated the overall prevalence rate, pointing out that the overall prevalence rate of IBS in the general population in China is 1.
4%-11.
5%, women are slightly higher than men, and young and middle-aged (18-59 Years old) is more common, and it has decreased among the elderly (≥60 years old)
.

Although IBS is very common in primary care and gastroenterology clinics, there are still many people who meet the symptoms of IBS who do not go to the hospital for treatment
.

The survey data of Guangdong Province shows that the outpatient rate of IBS patients who meet the Manning criteria is 19% in the community population, and the outpatient rate of IBS patients who meet the Rome II criteria is 22% [3]
.

The new consensus points out for the first time that only 25% of IBS patients visit the hospital, reflecting the fact that the rate of IBS patients is low, and reflecting from the side that the prevalence of IBS may be underestimated
.

2.
Etiology and pathogenesis At present, the pathophysiological mechanism of IBS has not been fully elucidated.
The new consensus believes that the intestinal-brain interaction is abnormal due to the combined action of multiple factors.
The peripheral factors mainly include abnormal motility, visceral hypersensitivity, and mucosal permeability.
Increase, intestinal immune activation, intestinal microecological disorders, abnormal processing of peripheral afferent signals in the central nervous system, as well as the interaction and interconnection of peripheral and central factors [4]
.

The consensus has updated the research progress of low-grade intestinal inflammation leading to IBS, pointing out that low-grade intestinal inflammation can participate in the pathogenesis of part of IBS by activating the intestinal immune-nervous system
.

In addition, mental and psychological factors are an important factor in the decision of patients with moderate to severe IBS to seek medical treatment
.

The new consensus emphasizes that both acute and chronic stress can induce or aggravate the symptoms of IBS.
Patients with IBS are often accompanied by anxiety and depression.
Among them, anxiety and depressive disorders have become significant risk factors for IBS due to their high incidence
.

3.
The diagnosis of IBS is mainly based on symptoms, and it is particularly important to use the same diagnostic criteria
.

Based on the clinical situation, the new consensus suggests that the Chinese IBS standards are as follows: recurrent abdominal pain, bloating, and abdominal discomfort, with any 2 or more of the following (① related to bowel movements; ② accompanied by changes in bowel frequency; ③ accompanied by stool traits or Appearance change), symptoms appeared at least 6 months before diagnosis, and met the above diagnostic criteria in the past 3 months
.

In addition, while affirming the value of symptoms in the diagnosis of IBS, the new consensus points out for the first time that IBS is not a diagnosis of exclusion, and targeted auxiliary examinations are feasible when necessary to confirm the diagnosis as soon as possible
.

In terms of alarm symptoms, the new consensus added “night defecation” and “nocturnal defecation” and “nocturnal defecation” and “nocturnal defecation” on the basis of “age>40 years old, positive blood in stool/fecal occult blood, anemia, abdominal mass, ascites, fever, weight loss, family history of colorectal cancer”.
"Family history of inflammatory bowel disease", while emphasizing the importance of unintentional "weight loss"
.

In the differential diagnosis, the new consensus points out that IBS and other functional defecation disorders and other functional bowel diseases have conversion and overlap, and the differentiation should be made based on the main symptoms
.

In addition, IBS often overlaps with dyspepsia, gastroesophageal reflux disease, etc.
The new consensus emphasizes that a comprehensive understanding of gastrointestinal symptoms and a clear diagnosis of overlapping diseases should be emphasized when evaluating the condition
.

4.
Treatment of IBS The overall goal of treatment is to improve symptoms and improve quality of life.
The new consensus emphasizes the importance of individualized comprehensive treatment strategies
.

The main treatment methods should include establishing effective doctor-patient communication, avoiding risk factors and adjusting life>
.

In terms of drug treatment, the new consensus recognizes that antispasmodics can improve the symptoms of IBS.
Patients with IBS have pain-related intestinal smooth muscle spasm.
Antispasmodics have a significant therapeutic effect on IBS abdominal pain and changes in stool characteristics.
Antidiarrheals are affirmed.
The improvement effect on IBS diarrhea, in addition to the traditional antidiarrheal agent loperamide, has increased the relevant research evidence of the therapeutic effect of octahedral montmorillonite on IBS-D patients
.

Regarding the choice of antibiotics, in addition to rifaximin, other antibiotics such as neomycin and norfloxacin can also alleviate the symptoms of IBS
.

Therefore, the new consensus changes "rifaximin" to "intestinal does not absorb antibiotics" in the recommendation of antibiotics
.

One of the highlights of the new consensus in the renewal of therapeutic drugs is the addition of relevant recommendations for secretagogues (Figure 1)
.

Secretagogues refer to drugs that promote the secretion of intestinal epithelial cells by activating related ion channels of intestinal epithelial cells, thereby softening stool and improving symptoms of constipation, including selective chloride channel agonists and guanylate cyclase-C agonists
.

It is proposed for the first time that secretagogues can improve the symptoms of IBS-C constipation, and the guanylate cyclase-C agonist (linaclotide) is also effective for abdominal pain
.

Figure 1: Recommendations for secretagogues in the "Experts Consensus Opinions on Irritable Bowel Syndrome in China in 2020" New recommendation? Anything happens for its reasons.
Linaclotide was listed in China in 2019, and it was recommended by the Chinese consensus level A only one year after the listing.
This is inseparable from its unique mechanism of action and good efficacy and safety
.

Advantage 1.
"One drug and two effects" unique mechanism of action Linaclotide is the world's first guanylate cyclase C (GC-C) agonist, which can increase cells by activating the GC-C receptor [5] The concentration of internal cyclic guanosine phosphate (cGMP) increases the secretion of intestinal juice and improves constipation [6]; it can also increase the concentration of extracellular cGMP, reduce visceral hypersensitivity and pain nerve sensitivity, relieve abdominal pain, and increase intestinal juice secretion/transport And reduce the dual mechanism of pain nerve sensitivity [7] (Figure 2)
.

Figure 2: Linaclotide "one-drug double-effect" mechanism diagram Advantages 2.
Linaclotide can effectively relieve a variety of symptoms, with stable efficacy and good safety.
The existing traditional treatment drugs for IBS have certain limitations and can only relieve IBS -C single symptoms
.

Linaclotide can effectively relieve a variety of symptoms
.

A number of randomized placebo-controlled studies with large samples have shown that linaclotide can significantly increase the patient’s full spontaneous defecation on the first day of treatment[8].
One week after the treatment, compared with the placebo group, the symptoms of constipation can be significantly improved while at the same time.
Improve abdominal pain, bloating and general symptoms [9,10]
.

Figure 3: Linaclotide effectively improves constipation and relieves abdominal pain and bloating.
IBS-C is a functional disease with recurrent symptoms.
Most patients require long-term treatment.
Therefore, for patients, it is very important to have a long-lasting and stable effect
.

The results of a multi-center, randomized, double-blind, placebo-controlled phase 3 clinical study of linaclotide in the United States showed that the application of linaclotide for 26 weeks can not only solve the symptoms of constipation and abdominal pain, but also Long-lasting and stable maintenance effect
.

In addition, the safety of linaclotide is good, most of the adverse reactions are only mild to moderate, and very few patients discontinue the drug due to adverse events
.

Figure 4: Linaclotide treatment for 26 weeks, improved spontaneous defecation and lasting stability.
Thanks to the above advantages, Linaclotide has not only obtained the latest consensus recommendation in China, but also has been strongly recommended by foreign guidelines
.

Among them, in the latest "2018 American College of Gastroenterology Guidelines for the Treatment of IBS" [12], Linaclotide is highly recommended for the overall symptom improvement of IBS-C with the highest level of evidence
.

Figure 5: The 2018 American College of Gastroenterology (ACG) guidelines recommend linaclotide for the improvement of the overall symptoms of IBS-C patients.
Part 3 summarizes the latest IBS Chinese expert consensus published in 2020.
It is the first time that secretagogues can improve IBS- C is a symptom of constipation, and especially emphasizes that the guanylate cyclase-C agonist is also effective for abdominal pain
.

Linaclotide, as the world’s first guanylate cyclase agonist, has a significant "one-drug and double-effect" treatment effect.
It provides an effective and safe method for IBS-C patients with limited drug treatment options.
Treatment options can further improve the quality of life of patients on the basis of improving symptoms, and truly meet the clinical needs of patients
.

References: [1]Alexander C Ford,et al.
Lancet.
2020 Nov 21;396(10263):1675-1688.
[2]Jasmine Turna,et al.
J Psychiatr Res.
2019 Nov;118:1-6.
[3] Gastrointestinal Functional Diseases Collaboration Group, Chinese Medical Association Gastroenterology Branch, et al.
Chinese Journal of Digestion.
2020; 40 (12): 803-818.
[4] Kok Ann Gwee, et al.
J Neurogastroenterol Motil.
2019 Jul 1;25(3):343-362.
[5]Kuhn M.
Physiol Rev.
2016 Apr;96(2):751-804.
[6]Thomas RH,Luthin DR.
Pharmacotherapy 2015;35(6): 613-630.
[7]Ford AC,et al.
Am J Gastroenterol 2014;109 Suppl 1:S2-26;quiz S27.
[8]Chey WD,et al.
Am J Gastroenterol.
2012 Nov;107(11): 1702-12.
[9]Rao S.
et al.
Am J Gastroenterol 2012;107:1714–1724[10]Quigley EMM.
et al.
Aliment Pharmacol Ther.
2013;37(1):49-61.
[11] Chey WD,et al.
Am J Gastroenterol.
2012 Nov;107(11):1702-12[12]Ford AC.
et al.
Am J Gastroenterol.
2018;113(Suppl 2):1-18.
Statement: This content It is only for Chinese medical and health professionals, and aims to provide scientific information to and only for medical and health professionals for personal learning and reference purposes
.

If you are not a medical and health professional, please do not participate or spread it
.

-End-This article is only used to provide scientific information to medical professionals and does not represent the platform's position
.