New irritable bowel guideline is imminent | Reports in Gastroenterology


Irritable bowel syndrome (RDS) is one of the most common diseases. This disease attracts media attention due to the large number of sufferers and the overlap of pathophysiology and therapy with the exciting areas of nutrition and microbiome. How extensive the increase in knowledge about pathophysiology, diagnostics and therapy is can be judged by the fact that the current treatment guideline expired in 2015, has been revised since then and a publication date has not yet been fixed. But I can already feel it, the publication date is imminent, because at this year's DGVS annual conference it was possible to guess in several lectures what the new guideline on the RDS will contain.

Proclaimed wrong treatment

Of course, there are many ways to jump on the train of attention. A very remarkable attempt by the Barmer Ersatzkasse (BEK) with the Barmer medical report 2019 resulted in a regular wave of publications under the title "Volksleiden RDS often treated incorrectly". what happened there? Who is treating who wrong here? Are we meant? The easiest way to answer this question would be to point your fingers at the general practitioner, because the report clearly shows that> 80% of those affected receive their diagnosis from their family doctor and only <7% from gastroentorologists. At best, our professional group can be minimally to blame for the incorrect treatment proclaimed by the BEK. But that would be too easy and not the right approach. It is worth reading the report in detail. The wrong treatment denounced is due to the fact that proton pump inhibitors (PPIs) were very often prescribed in the collective of RDS patients (up to 40%) and approximately 25% were given antidepressants. At first I smiled, maybe even laughed briefly, but then cried heartbreakingly over this 252-page, idiosyncratic interpretation. A look at the currently expired guideline for the treatment of RDS reveals that in Germany only Mebeverin could be prescribed at the expense of the GKV. Which preparations would the doctor report have found on the prescriptions if they did not come with the red prescription? For Mebeverin, the guideline also states that it was no more effective than placebo in the only placebo-controlled study. Now who is surprised that the experts and the readers do not prescribe any RDS medication at the expense of the SHI and therefore no preparations appear on the prescriptions of the BEK that could be included in the survey. In Germany, the preparations recommended in the guideline are either not prescribable at the expense of the SHI, withdrawn from the market or the indication has been restricted, failed in price negotiations or have not been applied for in Germany for approval. The high proportion of PPI prescriptions may be due to the fact that patients with a functional symptom also tend to have other functional symptoms. This is how the accepted Rome 4 criteria teach us. The high number of antidepressant prescriptions is probably explained by the co-morbidity reported in the guideline on depressive disorders.

Nevertheless, it is very pleased that a large statutory health insurance company that is committed to patient welfare would like to devote itself to the subject of RDS. The stage goal of getting attention has now been reached. One possible way of optimizing the manageable data situation would be to ensure that the preparations recommended in the guideline may be written on a red prescription, then the patients would be treated well and the recommendations given could then be counted in the next report.

View in the future

It is more interesting to look into the future. The announcements suggest that in the multifactorial pathophysiology, intestinal permeability is central. If we consider this carefully, we should take a closer look at the term “leaky gut”, because these two terms have a significant intersection. Currently, the term leaky gut is unfortunately deposited with considerable folklore and abundant voodoo and is occupied by diagnostic providers and non-medical practitioners. We have to be more active here, there is a considerable need for explanation, which is located in gastroenterology. It is also becoming apparent that the topics of nutrition and the microbiome will occupy central positions. Due to the excellent worldwide study situation, the FODMAP diet has become a central part of therapy. Together with other basic measures, especially stress-controlling procedures, these should be offered before the use of medicinal measures. Drug therapy can follow basic therapy. Exciting innovations are announced here. However, these will probably continue to avoid Germany, at least when it comes to prescribability at the expense of statutory health insurance.