Irritable Bowel Syndrome and Complementary Health Approaches: What the Science Says

Gut-Directed Hypnotherapy

Some studies have suggested benefit of gut-directed hypnotherapy for IBS symptoms, including gastrointestinal symptoms, anxiety, depression, disability, and health-related quality of life. Significant relief from pain-related functional gastrointestinal pain disorders in children has been reported after hypnotherapy compared with standard care or waitlist approaches. Clinical guidelines issued in 2021 by the American College of Gastroenterology recommend that gut-directed psychotherapies, such as gut-directed hypnotherapy, be used to treat global IBS symptoms. (The recommendation is conditional, with “very low quality of evidence.”)

What Does the Research Show?

• Clinical guidelines issued in 2021 by the American College of Gastroenterology recommend that gut-directed psychotherapies, such as gut-directed hypnotherapy, be used to treat global IBS symptoms. (The recommendation is conditional, with “very low quality of evidence.”)
• A  2020 systematic review and network meta-analysis of 41 randomized controlled trials involving a total of 4,072 participants found that gut-directed hypnotherapy was more efficacious than either education and/or support or routine care in adults with IBS. However, other psychological therapies were analyzed as well, and none was superior to another; cognitive behavioral therapy and gut-directed hypnotherapy had the largest evidence base and were the most efficacious over the long term.
• A 2022 systematic review and meta-analysis of 33 randomized controlled trials involving a total of 2,657 children with functional abdominal pain disorders found that hypnotherapy may be considered as a treatment for these disorders in childhood.
• A 2015 review of seven randomized trials of gut-directed hypnotherapy for IBS found that six of those trials reported a significant reduction in overall gastrointestinal symptoms compared to supportive therapy only. The reviewers concluded that gut-directed hypnotherapy has durable efficacy in patients with IBS, but there is not enough evidence to determine whether hypnotherapy belongs as a primary or adjunctive therapy option for patients with IBS.

Safety

• Gut-directed hypnosis is generally considered safe and tolerable among children and adults when led by licensed hypnotherapists with special training in this technique.

Peppermint Oil

There is some evidence that enteric-coated peppermint oil capsules may be modestly efficacious, in the short term, in reducing several common symptoms of IBS, in particular abdominal pain, bloating, and gas. Long-term efficacy has not been established. Clinical guidelines issued in 2021 by the American College of Gastroenterology recommend the use of peppermint to provide relief of global IBS symptoms. (The recommendation is conditional, with “low quality of evidence.”)

What Does the Research Show?

• Clinical guidelines issued in 2021 by the American College of Gastroenterology recommend the use of peppermint to provide relief of global IBS symptoms. (The recommendation is conditional, with “low quality of evidence.”)
• A 2020 randomized, double-blind trial of 190 patients in the Netherlands found that neither small-intestinal-release nor ileocolonic-release peppermint oil, administered over 8 weeks,  produced statistically significant reductions in abdominal pain response or overall symptom relief, when using U.S. FDA/European Medicines Agency recommended endpoints. However, the small-intestinal-release peppermint oil did produce significant reductions in abdominal pain, discomfort, and IBS severity. 
• A 2020 systematic review and network meta-analysis of 51 randomized controlled trials involving 4,644 patients evaluated soluble fiber, antispasmodic drugs, peppermint oil, and gut-brain neuromodulators for IBS. The reviewers found peppermint oil was ranked first for efficacy with regard to improvement in global IBS symptoms, on the basis of data from six trials. However, the reviewers also noted that only 13 trials were at low risk of bias, and therefore, there is likely to be considerable uncertainty around these findings.
• A 2021 randomized double-blind, placebo-controlled trial involving 133 participants compared the effects of peppermint oil to placebo for relieving IBS symptoms. The results showed clinically significant improvements after 6 weeks in both groups. However, there were no statistically significant differences between peppermint oil and placebo on any of the outcome measures (improvement in IBS-Severity Scoring System scores, global improvement of IBS symptoms, and adequate relief of symptoms). Although there were no serious adverse events, there was a higher rate of adverse events, as well as adverse event-related dropouts in peppermint oil compared to placebo.
• A 2014 systematic review and meta-analysis of 9 studies involving a total of 726 participants found peppermint oil to be superior to placebo for global improvement of IBS symptoms and improvement in abdominal pain.

Safety

• Non-enteric coated forms of peppermint oil may cause or worsen heartburn symptoms, but otherwise appears to be generally safe over the short term.

Herbal Remedies

There is evidence to suggest some herbal remedies improve IBS symptoms. However, much of the data available is based on studies with inadequate methodology and small sample populations.

What Does the Research Show?

• A 2021 network meta-analysis of 28 studies in 3,323 people found low-quality evidence that Chinese herbal products could be beneficial for patients with IBS in relieving their various clinical symptoms and improving their quality of life. 
• A 2017 double-blind, randomized, placebo-controlled trial involving 99 participants found that those who received an herbal remedy (IQP-CL-101) containing a mixture of curcuminoids and essential oils from different Curcuma species, fish oil, peppermint oil, caraway oil, and vitamins B1, B9, and D3, had a significant reduction in IBS symptoms compared to placebo.
• A  2019 randomized trial of 240 women with diarrhea-predominant irritable bowel syndrome (IBS-D) found that crofelemer, an active compound from the latex of the plant Croton lechleri, had no significant effect compared with placebo on the number of days without pain and discomfort. However, in an analysis conducted after the trial ended, crofelemer did improve abdominal pain compared with placebo based on the FDA abdominal pain monthly responder endpoint, which suggests that crofelemer may have a role in the management of pain in IBS-D.
• A 2006 Cochrane review of 75 randomized controlled trials involving a total of 7,957 participants with IBS concluded that while some herbal remedies may improve IBS symptoms, positive findings from less rigorous trials should be interpreted with caution due to inadequate methodology, small sample sizes, and lack of confirming data.

Safety

• Herbal supplements may contain dozens of compounds and all of its ingredients may not be known.
• Some herbs can interact with medications. For example, St. John’s wort is a potent inducer of both cytochrome P-450 enzymes and intestinal P-glycoprotein. Clinically significant interactions have been documented with St. John’s wort and cyclosporine, the antiretroviral agent indinavir, oral contraceptives, coumadin, digoxin, and benzodiazepines, among others.
• Some herbs can cause serious side effects. For example, comfrey and kava can cause liver toxicity.

Acupuncture

In sham-controlled, randomized trials, acupuncture was found to be no better than placebo for IBS symptom severity or health-related quality of life. In other studies, acupuncture appeared to provide greater benefits than two antispasmodic drugs, although the studies could not rule out that these benefits may have been due to patient preferences or expectations of improvement.

What Does the Research Show?

• A 2021 systematic review and meta-analysis of 24 studies involving 3,220 participants with IBS found that in studies that compared acupuncture to pharmacotherapy, acupuncture was superior in relieving IBS symptoms. When used as an adjuvant intervention to other treatments, including pharmacotherapy and herbal medicine, acupuncture helped to improve clinical efficacy in treating IBS symptoms. However, acupuncture was not superior to sham acupuncture for improving IBS symptoms. The authors noted that the quality of the evidence was low to moderate in the reviewed studies.
• A 2019 meta-analysis of 41 studies involving a total of 3,440 participants showed that acupuncture was no more effective than sham acupuncture for symptoms of IBS, but there was some evidence that acupuncture could be helpful when used in addition to other forms of treatment.
• A 2014 meta-analysis of six randomized, placebo-controlled trials found some benefit of acupuncture for IBS symptoms; however, only one of the six studies showed a positive effect. The authors concluded that data are insufficient to establish long-term results or to recommend acupuncture as first-line treatment.
• A 2012 Cochrane review of 17 randomized controlled trials involving a total of 1,806 participants found no evidence of an improvement with acupuncture compared to a sham acupuncture control for symptom severity or quality of life. The review also included four Chinese comparative effectiveness trials and found acupuncture to provide greater benefits than two antispasmodic drugs (pinaverium bromide and trimebutine maleate), which have been known to provide modest benefits for IBS symptoms. However, it is unclear if the benefits of acupuncture in these studies were due to patient preferences or expectation of improvement.

Safety

• Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of non-sterile needles and improper delivery of treatments.
• When not delivered properly, acupuncture can cause serious adverse effects, including infections, bleeding, pneumothorax, and injury to the central nervous system.

Yoga

A small amount of evidence suggests that yoga and other types of exercise may be helpful for IBS.

What Does the Research Show?

• A 2022 Cochrane systematic review of 5 randomized controlled trials involving 218 people with IBS suggested that physical activity comprising yoga, treadmill exercise, or support to increase physical activity may improve symptoms but not quality of life or abdominal pain in people diagnosed with IBS. The authors of the study cautioned, however, that the quality of the evidence was very low.

Safety

• Yoga is generally considered a safe form of physical activity for healthy people when performed properly, under the guidance of a qualified instructor.
• Serious injuries are rare, and the most common injuries are sprains and strains. The risk of injury associated with yoga is lower than that for higher impact sports activities.

Meditation and Mindfulness

There is little research on the benefits of meditation and mindfulness for improving health in people with IBS, and the results are not conclusive. 

What Does the Research Show?

• A 2018 review of 5 studies involving 695 participants with IBS concluded that in addition to receiving conventional care, an e-health mindfulness intervention along with patient education or cognitive behavioral therapy can benefit general health in people with health conditions including IBS.
• A 2019 systematic review and meta-analysis of 2 studies involving 165 participants found that those assigned to mindfulness meditation symptoms had no greater improvement compared with the control group. The authors noted that the evidence was of low quality. 

Safety

• Meditation and mindfulness practices usually are considered to have few risks. 
• Few studies have examined mindfulness practices for potentially harmful effects, so there is not enough evidence to make definitive statements about safety.

Relaxation Therapy

What Does the Research Show?

There is little research on the use of relaxation therapy for IBS, and the results are not conclusive.

• A 2021 review and analysis of 6 studies in 278 people with IBS demonstrated no difference in overall response between body-based therapy and placebo with moderate heterogeneity and low confidence in estimates.

Safety

• Relaxation techniques are generally considered safe for healthy people. In most research studies, there have been no reported negative side effects. However, occasionally, people report negative experiences such as increased anxiety, intrusive thoughts, or fear of losing control.

References