Background
Irritable bowel syndrome (IBS) is a highly prevalent and economically burdensome condition; and pain is often the most unpleasant, disruptive, and difficult‐to‐treat symptom. Visceral hypersensitivity is a common feature driving pain in IBS, suggesting that neuropathic mechanisms may be implicated. We conducted a systematic review of available evidence to examine the role of anti‐neuropathic medicines in the management of pain in IBS.
Methods
We systematically searched scientific repositories for trials investigating conventional oral, and/or parenteral, pharmaceutical antineuropathic treatments in patients with IBS. We summarized key participant characteristics, outcomes related to pain (primary outcome), and selected secondary outcomes.
Key results
We included 13 studies (n = 629 participants): six investigated amitriptyline, three duloxetine, three pregabalin, and one gabapentin. There was considerable methodological and statistical heterogeneity, so we performed a narrative synthesis and limited meta‐analysis. Amitriptyline was most extensively studied, though only in diarrhea‐predominant patients. In individual trials, amitriptyline, pregabalin and gabapentin generally appeared beneficial for pain outcomes. While duloxetine studies tended to report improvements in pain, all were un‐controlled trials with high risk of bias. Meta‐analysis of three studies (n = 278) yielded a pooled relative‐risk of 0.50 (95%CI 0.38–0.66) for not improving with anti‐neuropathic agent vs control. We did not identify any eligible studies investigating the role of parenteral anti‐neuropathics.
Conclusions and inferences
Anti‐neuropathic analgesics may improve pain in IBS, and deserve further, high‐quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Investigation of amitriptyline’s efficacy in non‐diarrhea‐predominant subtypes is currently lacking, and we recommend particular caution for its use in IBS‐C.