Management Of Functional Gastrointestinal Disorders Ⅲ
Nov 09, 2023
Pharmacotherapy
Kev tswj kev lom neeg ntawm FGID suav nrog kev kho cov kab mob pathophysiology (piv txwv li neuromodulators los kho visceralhypersensitivity) lossis kho cov tsos mob (xws li antiemetics rau kev kho mob plab lossis laxatives los kho cem quav). Ntau lub algorithms muaj los pab qhia qhov no rau kev ua haujlwm dyspepsia thiab IBS (Daim duab 2).10,41 Rau qhov kev tshuaj xyuas no, cov tsos mob-raws li txoj hauv kev tau nthuav tawm.
Mob
Opiates yuav tsum zam kom tsis txhob muaj kev cuam tshuam nrog kev ywj pheej, kev kam rau siab, thiab kev quav tshuaj, thiab tuaj yeem ua rau muaj tus kab mob narcoticbowel uas ua rau tsam plab, cem quav, xeev siab, thiab paradoxical nce hauv qhov mob nrog nce koob tshuaj opiates.42 Hloov chaw, thawj kab kev tswj xyuas qhov mob cuam tshuam nrog antispasmodics. mob colicky. Hauv cov neeg mob uas muaj kev tiv thaiv ntau dua, feem ntau ua rau mob kub hnyiab / mob neuropathic, neuromodulators yog siv cov kab mob thib ob.
Thawj kab: antispasmodic
Antispasmodics muaj txiaj ntsig zoo rau kev mob plab hauv plab hauv IBS.Muaj pov thawj zoo rau hyoscine (10–20 mg peb zaug ib hnub (TDS); NNT 3) thiab dicycloverine (10–20 mg tds; NNT 4), kev xav tuaj yeem ua rau cov tshuaj anticholinergic sab. cov teebmeem ntawm qhov muag qhuav thiab lub qhov ncauj qhuav, thiab tuaj yeem ua rau cem quav. Kuj tseem muaj pov thawj rau cov roj peppermint (xws li Coppermine 2 capsules tds; NNT 4). Nws tuaj yeem ua rau mob plawv, yog li nws yuav zam tau zoo tshaj plaws rau cov neeg mob uas muaj kev sib koom ua keGORD.30 Cov pov thawj rau mebeverine (135 mg TDS) tsis zoo li, txawm li cas los xij, nws tau txais txiaj ntsig zoo thiab tuaj yeem ua tau zoo heev hauv pawg neeg mob uas tsis teb rau. Lwm cov tshuaj antispasmodics.30 Peb qhov kev coj ua yog sim tshuaj tua kab mob thib ob yog tias thawj zaug tsis tswj cov mob plab plab.
Kab thib ob: neuromodulators
Antidepressants.
Feem ntau siv cov tshuaj tiv thaiv kev ntxhov siab yogtricyclic antidepressants (TCAs) thiab xaiv serotonin reuptakeinhibitors (SSRIs). Raws li txoj cai, cov tshuaj tiv thaiv kev ntxhov siab txhim kho cov tsos mob, tshwj xeeb yog mob plab, nrog rau kev puas siab puas ntsws inFGID, thiab cov txiaj ntsig tau nce ntxiv nyob rau theem nrab piv nrog kev saib xyuas thawj zaug, uas tej zaum yuav cuam tshuam txog kev puas siab puas ntsws ntau dua thiab mob comorbidity hauv yav dhau los.31 Rau txhua plaub tus neeg mob kho nrog tshuaj tua kab mob. , ib tug yuav tau zoo.
Feem ntau cov tshuaj tiv thaiv kev ntxhov siab yuav muaj GI cov kev mob tshwm sim thiab tuaj yeem ua rau cem quav lossis raws plab (cov khoom siv ntxiv S1), kev xaiv koj cov tshuaj tiv thaiv kev ntxhov siab kuj tuaj yeem pab kho tus cwj pwm hloov hauv IBS. TCAs (xws li amitriptyline) muaj txiaj ntsig zoo rau cov neeg mob raws plab los ntawm kev ncua GI qeeb, thaum SSRIs (xws li sertraline, citalopram, fluoxetine) muaj txiaj ntsig zoo rau cov neeg mob cem quav byaccelerating transit.
Tsis muaj RCTs ntawm serotonin noradrenergicreuptake inhibitors (xws li duloxetine) hauv FGID, txawm li cas los xij, qhib-labelstudies rau cov neeg mob IBS thiab comorbid ntxhov siab vim thiab kev nyuaj siab qhia tau hais tias nws tau txais txiaj ntsig zoo ntawm koob tshuaj 60 mg ib hnub twg thiab txhim kho IBS cov tsos mob thiab kev nyuaj siab. thiab kev ntxhov siab.43,44
Kev kho mob nrog cov tshuaj tiv thaiv kev ntxhov siab yog rau qhov nruab nrab ntawm 18 lub hlis thiab nres thaum cov neeg mob tsis muaj tsos mob tsawg kawg yog 6 lub hlis. Txhawm rau txhim kho kev ua raws, nws yog ib qho tseem ceeb kom paub meej rau cov neeg mob tias cov tshuaj tiv thaiv kev nyuaj siab yog siv feem ntau los tsom rau cov tsos mob ntawm IBS, tshwj xeeb yog mob, tsis yog mus ob peb vas. . Nws yog ib qho tseem ceeb ceeb toom cov neeg mob txog cov kev mob tshwm sim thiab, yog tias tsim nyog, pib ib koob tshuaj tsawg heev (subtherapeutic) thiab ua hauj lwm maj mam, kom txo tau cov teeb meem tsis zoo thiab yog li txhim kho kev ua raws cai. Peb yuav ceeb toom tiv thaiv kev siv ntau dua ib qho tshuaj tiv thaiv kev ntxhov siab nyob rau lub sijhawm tshwj tsis yog tias muaj kev txawj ntse ua qhov no.
Gabapentinoids. Pregabalin thiab gabapentin feem ntau yog siv rau hauv cov mob mob ntev thiab muaj lub luag haujlwm hauv kev kho mob visceral hypersensitivity hauv FGID. Pregabalin yog txuam nrog kev txhim kho ntawm IBS cov tsos mob (mob plab, raws plab, thiab mob plab) piv nrog cov placebo, yog li yog ib qho kev xaiv zoo rau IBS-D.45 Qhov no yuav tsum tau pib ntawm qhov koob tshuaj qis ntawm 50 mg ob zaug ib hnub (bd) thiab nce zuj zus. nyob rau hauv txoj kab nrog cov symptomatic teb, mus rau qhov siab tshaj plaws ntawm 300 mg bd, txawm hais tias nws tsis yog ib txwm yuav tsum tau nce ntau tshaj 225 mg bd (3 × 75 mg ntsiav tshuaj bd).45Nws ua rau hnyav nce, yog li tej zaum yuav tsis yog qhov kev xaiv zoo tshaj plaws rau cov neeg rog rog. Cov kws kho mob yuav tsum paub tias nws muaj kev quav yeeb quav tshuaj thiab tam sim no suav tias yog tshuaj ntawm kev tsim txom, yog li yuav tsum tau xaiv nrog ceev faj hauv qee cov neeg mob. Gabapentin yog lwm txoj hauv kev tab sis zoo li muaj qhov tshwm sim tsis zoo. Txawm hais tias tsis muaj RCTs ntsuas qhov ua tau zoo ntawm gabapentin ntawm IBS cov tsos mob lossis qhov zoo tshaj plaws koob tshuaj rau cov tsos mob txhim kho, ib txoj kev tshawb fawb pom tau tias, cov neeg mob siv 300 mg gabapentin txhua hnub, muaj qhov txo qis hauv qhov tsis haum rau qhov mob thiab nce qhov mob, mob plab, thiab tsis xis nyob.46
Mob plab
Thawj kab: loperamideLoperamide (Imodium) txo cov quav ntau zaus thiab txhim kho cov quav hauv plab hauv IBS-D, txawm li cas los xij, nws tsis zoo ntawm kev txo qhov mob plab lossis tsam plab, yog li nws tsis zoo rau hauv IBSpatients.30 Loperamide-simethicone chewable khoom (Imodiumplus) yog qhov zoo dua. zam tau thiab ua rau kom sai dua los ntawm kev mob raws plab thiab pab ntau dua los ntawm qhov tsis xis nyob hauv plab piv nrog loperamide ib leeg lossis ib qho placebo thiab, yog li ntawd, qhov no yuav tsum tau pom zoo rau cov neeg mob uas muaj IBS-D.47 Cov neeg mob tuaj yeem hais kom noj ob ntsiav tshuaj pib nrog thiab tom qab ntawd ib ntsiav tshuaj tom qab. txhua cov quav uas tsis muaj ntaub ntawv kom txog thaum zawv plab nres (txog li yim ntsiav tshuaj ib hnub twg).
Ob kab: ondansetronOndansetron, 5HT3 antagonist, txhim kho cov quav sib xws, zaus, ceev, thiab tsam plab tab sis tsis mob plab piv nrog cov placebo lossis mebeverine rau cov neeg mob IBS-D, yog li nws yog qhov tshwj xeeb tshaj yog rau cov neeg mob uas muaj teeb meem nrog kev hloov hauv plab. cwj pwm tshaj qhov mob.48 Raws li nws yog ib qho antiemetic, nws kuj tuaj yeem txhim kho xeev siab rau cov neeg mob uas muaj overlappingdyspepsia. Alosetron yog tus ua ntej rau ondansetron rau IBS-D, txawm li cas los xij, nws tau cuam tshuam nrog ischemic colitis thiab yog li ntawd rho tawm. Hauv kev txheeb xyuas cov neeg mob nrog IBS-D thiab IBS-M, cov neeg mob ntawm 5HT3 antagonists ua tau zoo dua li cov oneluxadoline thiab rifaximin (saib tom qab), yog li nws tsim nyog xav txog kev siv ondansetron ntxov rau cov neeg mob IBS-D.49.
Cov kab thib peb: rifaximin thiab eluxadolineRifaximin yog cov tshuaj tua kab mob uas tsis tuaj yeem siv los kho cov kab mob GI. Ib qho kev ntsuam xyuas meta pom tau tias rifaximinis zoo dua rau cov placebo kom txo cov tsos mob ntawm raws plab thiab plab hnyuv hauv cov neeg mob uas tsis cem quav nrog IBS, txawm li cas los xij, nws tsis cuam tshuam rau qhov mob.30,50 Tsis ntev los no cov pov thawj tsis tau tshaj tawm qhia tias nrog 550 mg bd rau 2 lub lis piam, cov nyhuv no yuav yuav txhawb nqa tsawg kawg 12 lub lis piam tom qab noj cov tshuaj tua kab mob. Txawm li cas los xij, rifaximin tseem tsis tau tso cai siv rau hauv IBS hauv UK thiab cov teebmeem mus sij hawm ntev ntawm themicrobiota tsis paub, yog li nws nyuaj rau ua pov thawj-raws li cov lus pom zoo txog cov tshuaj tua kab mob tam sim no.Eluxadoline yog ib qho opioid receptor antagonist uas txo cov quav zaus thiab txhim kho. Cov tsos mob ntawm IBS thoob ntiaj teb, txawm li cas los xij, vim yog kev koom tes nrog tus mob pancreatitis, nws raug zam rau cov neeg mob uas muaj kev pheej hmoo rau tus mob pancreatitis (xws li keeb kwm ntawm pancreatitis, yav dhau los cholecystectomy, gallstones oralcohol). leej twg muaj lub zais zis tsis zoo, eluxadoline tuaj yeem pab txo cov quav ntau zaus thiab txhim kho qhov mob ntau dua 12 lub lis piam piv nrog cov placebo. Ib koob tshuaj ib txwm yog 100 mgbd tab sis qhov no tuaj yeem txo mus rau 75 mg bd thaum muaj kev phiv (xws li xeev siab, mob plab, cem quav, thiab ntuav).51
cem quav
Thawj kab: osmotic laxativesPolyethylene glycol (PEG)-raws li laxatives (xws li Movicol thiab Laxido) nrog rau lactulose pab nqus dej rau hauv plab ua rau cov quav. Txawm hais tias lawv muaj feem cuam tshuam nrog kev nce ntau zaus ntawm plab hnyuv, lawv tsis txo qhov mob hauv IBS. Lactulose tuaj yeem ua rau tsam plab zuj zus. Hauv kev xyaum, nws yog ib qho tseem ceeb rau siv osmotic laxatives los txhim kho cov quav ntau zaus rau cov neeg mob cem quav / IBS-C tab sis qhov no yuav tsum tau ua ke nrog lwm cov tshuaj los pab nrog lwm cov tsos mob xws li mob.
Ob kab: prucalopridePrucalopride yog ib qho kev xaiv 5HT4 agonist uas ua raws li aprokinetic hauv plab. Ib qho RCT tau qhia txog nws txoj kev ua tau zoo hauv txhua tus neeg mob nrog cem quav thiab hauv cov poj niam uas muaj cem quav ntev uas cov tshuaj laxatives ua tsis tau zoo los muab kev pab txaus.52 Raws li NICE, nws tau tso cai rau cov poj niam uas kho nrog ob lub laxatives ua tsis tiav. Ib koob tshuaj yog 2 mg ib hnub twg. Kev noj tshuaj ntau dua 4 mg txhua hnub yuav ua rau muaj kev txhim kho hauv kev sib zog dua li qhov stoolfrequency tab sis kuj tseem yuav cuam tshuam nrog cov kev mob tshwm sim ntau dua (xws li mob taub hau, xeev siab, thiab raws plab).52,53 Cov neeg mob uas tsis teb thawj 4 lub lis piam tsis zoo li. ua li ntawd nrog kev kho ntau dua, yog li qhov no tuaj yeem nres. Prucalopride kuj ua raws li asa gastric prokinetic, yog li nws tuaj yeem pab tau rau cov neeg mob dyspepsia / gastroparesis-hom tsos mob thiab yuav yog ib qho kev xaiv zoo rau cov neeg mob uas muaj IBS-C thiab kev ua haujlwm dyspepsia sib tshooj.
Kab thib peb: secretagoguesYog hais tias cov kev ntsuas saum toj no ua tsis tiav, ces qhov kev xaiv thib peb yog siv cov secretagogues (linaclotide thiab lubiprostone) uas txhim kho plab hnyuv ntau zaus thiab tag nrho cov tsos mob ntawm IBS. Qee cov neeg mob muaj qhov tsis txaus siab raws plab nrog qhov no yog li nws yuav tsim nyog txo qhov koob tshuaj hauv qhov xwm txheej ntawd.Linaclotide ua rau muaj cov tshuaj chloride thiab bicarbonatesecretion ntau ntxiv rau hauv plab lumen uas ua rau muaj kua dej ntau ntxiv thiab cov hnyuv. Nws txhim kho lub plab zom mov thiab txo qhov mob plab piv nrog cov placebo; cov nyhuv no zoo ib yam txawm tias koob tshuaj (290 ug) txo mus rau 72 ug, uas txo cov kab mob raws plab (ib qho ua rau tsis ua haujlwm ntxiv) thiab yog li ntawd yuav txhim kho kev ua raws.54,55Lubiprostone ntawm koob tshuaj 8 ug bd txhim kho mob plab, plab, thiab quav. zaus hauv IBS-C ntau dua li cov placebo tab sis tuaj yeem cuam tshuam nrog xeev siab.56
Functional dyspepsia Qhov no yog qhov thib ob feem ntau FGID thiab tuaj yeem muab faib mus rau hauv epigastric mob syndrome (EPS), tus cwj pwm los ntawm epigastricpain thiab kub hnyiab tsis cuam tshuam rau cov pluas noj, thiab postprandial distresssyndrome (PDS) uas ua rau ntxov satiety, postprandial fullness, xeev siab, thiab epigastric bloating. Ib feem ntawm cov neeg mob nrog FDwill kuj muaj qhov me me mus rau nruab nrab qeeb hauv lawv lub plab khoob (Fig 2b).
First line: proton pump inhibitors and H pylori eradication therapy A meta-analysis showed that H pylori eradication provides significant symptomatic benefits in the long term (>6 lub hlis) ntau dua li lub sijhawm luv (<6 months); but patients with functional dyspepsia are more likely to experience side effects including diarrhea. It is therefore important to encourage them to remain compliant and complete the course and to ensure eradication following this if they have ongoing symptoms. Patients who are proton pump inhibitor (PPI) responsive should be continued on the lowest dose needed to manage symptoms, and if this is not effective, it should be stopped.10
Kev kho thib ob: H2 blockers thiab prokineticsH2 blockers. Hauv kev tshuaj ntsuam meta-kev kho mob rau kev ua haujlwm tsis zoo, H2 antagonists (xws li ranitidine) piv rau, yog tias tsis muaj txiaj ntsig zoo dua, PPIs. Qhov no tsis yog qhov xav tsis thoob vim qhov tseem ceeb ntawm lub luag haujlwm tseem ceeb ua si los ntawm mast hlwb thiab histaminein txhim kho kev ua haujlwm dyspepsia.10 Txhais qhov kev coj ua no, nws tsim nyog sim H2 blockers rau cov neeg mob FD txawm tias thaum PPIs ua tsis tiav, txawm hais tias, hauv huab cua tam sim no, cov khoom siv. teeb meem nrog cov tshuaj no tuaj yeem ua rau qhov kev coj ua nyuaj.
Prokinetics. Prokinetics tuaj yeem siv rau hauv PDS, tshwj xeeb tshaj yog tias muaj kev tso pa tawm qeeb. Lawv txhim kho cov tsos mob tab sis tsis zoo ntawm lub neej.57 Ntau yam prokinetics sawv cev hauv RCTs tsis muaj nyob hauv UK (xws li itopride, acotiamide, cisapride, thiab mosapride), Txawm li cas los xij, cov no tsis zoo dua li domperidone, uas muaj nyob hauv UK. Domperidone tau cuam tshuam nrog nce QTintervals uas txwv tsis pub siv, txawm li cas los xij, rau cov neeg mob uas muaj QT lub sijhawm tsis zoo, domperidone tuaj yeem sim ua kom muaj kev nyab xeeb, txawm hais tias nws yog ib qho tseem ceeb uas yuav tsum tau kuaj xyuas electrocardiography thaum tus neeg mob tau tsim los ntawm domperidone. Tsis muaj kev sim tshuaj ntsuam xyuas lwm yam prokinetics (xws li metoclopramide thiab erythromycin) hauv FD, txawm li cas los xij, theoretically, cov no tuaj yeem siv rau lub sijhawm luv.
Kab thib peb: neuromodulatorsCov pov thawj rau cov tshuaj tiv thaiv kev ntxhov siab hauv kev ua haujlwm dyspepsia tsis pom tseeb tab sis zoo li muaj lub luag haujlwm rau cov tshuaj TCAs qis xws li amitriptyline (10-30 mg nocte) lossis imipramine (25 mg txhua hnub rau 2 lub lis piam tom qab ntawd 50 mg txhua hnub) rau cov neeg mob. mob epigastric (xws li mob epigastric). Mirtazapine yog nce nrov, tshwj xeeb tshaj yog rau cov neeg mob uas muaj cov tsos mob postprandial (xws li tsis xis nyob, fullness, thiab xeev siab tom qab noj mov). Nws txhim kho cov tsos mob thiab kev noj zaub mov zoo txawm tias tsis muaj kev sib koom ua ke ntawm kev nyuaj siab thiab kev ntxhov siab thiab ua rau lub cev hnyav, sow yuav zoo tagnrho rau cov neeg mob uas muaj cov tsos mob ntawm postprandial fullness uas tsis hnyav.60 Nws kuj txhim kho kev pw tsaug zog thiab lub siab lub ntsws uas yuav muaj txiaj ntsig zoo rau cov tsos mob thoob ntiaj teb. Cov neeg mob yuav tsum pib noj 15 mg nocte thiab nce txhua hli mus rau qhov siab tshaj plaws ntawm 45 mg. Ameta-analysis tau pom tias tsis muaj lub luag haujlwm rau SSRIs (egsertraline, fluoxetine, lossis citalopram) hauv FD.58 Buspirone yog ib qho anxiolytic uas tuaj yeem txhim kho plab hnyuv thiab tuaj yeem muaj txiaj ntsig zoo rau cov neeg mob nrog postprandial fullness thiab satiety thaum ntxov tab sis cuam tshuam nrog cov kev mob tshwm sim tsis zoo. ntawm kiv taub hau thiab somnolence yog li tsis yog thawj qhov kev xaiv ntawm neuromodulator.10
Xaus
FGIDs muaj ntau tab sis cov kab mob nyuaj uas cuam tshuam nrog ntau yam mob thiab cuam tshuam txog kev puas siab puas ntsws. Raws li theetiology ntawm cov kab mob no tseem tsis tiav nkag siab tsis muaj kev kho rau lawv. Kev kho mob suav nrog kev kho mob zoo thiab kev sib koom ua ke los kho tus neeg mob es tsis muaj kab mob, siv tus qauv biopsychosocial.
Ntuj Herbal Tshuaj Rau Relieving cem quav-Cistanche
Cistanche yog ib tug genus ntawm parasitic nroj tsuag uas belongs rau tsev neeg Orobanchaceae. Cov nroj tsuag no paub txog lawv cov khoom siv tshuaj thiab tau siv nyob rau hauv Cov Tshuaj Hauv Suav Teb (TCM) rau ntau pua xyoo. Cov hom Cistanche feem ntau pom muaj nyob hauv thaj av qhuav thiab suab puam ntawm Tuam Tshoj, Mongolia, thiab lwm qhov chaw ntawm Central Asia. Cistanche nroj tsuag yog tus cwj pwm los ntawm lawv cov fleshy, yellowish stems thiab muaj nuj nqis heev rau lawv cov txiaj ntsig kev noj qab haus huv. Hauv TCM, Cistanche ntseeg tau tias muaj cov khoom siv tonic thiab feem ntau yog siv los kho lub raum, txhim kho qhov tseem ceeb, thiab txhawb kev ua haujlwm ntawm kev sib deev. Nws kuj yog siv los daws cov teeb meem ntsig txog kev laus, qaug zog, thiab kev noj qab haus huv tag nrho. Thaum Cistanche muaj keeb kwm ntev ntawm kev siv tshuaj ib txwm siv, kev tshawb fawb tshawb fawb txog nws txoj kev ua tau zoo thiab kev nyab xeeb tsis tu ncua thiab txwv. Txawm li cas los xij, nws muaj ntau yam bioactive compounds xws li phenylethanoid glycosides, iridoids, lignans, thiab polysaccharides, uas yuav pab tau rau nws cov tshuaj.
Wecistanche's cistanche hmoov, cistanche ntsiav tshuaj, cistanche tsiav tshuaj, thiab lwm yam khoom yog tsim los siv suab puam cistanche raws li raw cov ntaub ntawv, tag nrho cov no muaj ib tug zoo ntxim rau relieving cem quav. Cov txheej txheem tshwj xeeb yog raws li hauv qab no: Cistanche ntseeg tau tias muaj cov txiaj ntsig zoo rau kev tshem tawm cem quav raws li nws cov kev siv ib txwm siv thiab qee cov tshuaj uas nws muaj. Txawm hais tias kev tshawb fawb tshawb fawb tshwj xeeb ntawm Cistanche qhov cuam tshuam rau cem quav yog txwv, nws tau xav tias muaj ntau lub tswv yim uas yuav ua rau nws muaj peev xwm txo tau cem quav. Laxative nyhuv: Cistanche tau ntev tau siv nyob rau hauv Tsoos Suav Tshuaj raws li ib tug tshuaj rau cem quav. Nws ntseeg tau tias muaj cov nyhuv laxative me me, uas tuaj yeem pab txhawb kev zom zaub mov thiab ua rau cem quav. Cov nyhuv no tuaj yeem raug ntaus nqi rau ntau lub tebchaw nyob hauv Cistanche, xws li phenylethanoid glycosides thiab polysaccharides. Moistening plab hnyuv: Raws li kev siv ib txwm siv, Cistanche suav hais tias muaj cov khoom siv moisturizing, tshwj xeeb yog tsom rau cov hnyuv. Txhawb nqa dej thiab lubrication ntawm cov hnyuv yuav pab tau cov cuab yeej soften thiab yooj yim dua, yog li no relieving cem quav. Anti-inflammatory Effect: cem quav tej zaum yuav txuam nrog o nyob rau hauv lub plab zom mov. Cistanche muaj qee qhov sib txuas, suav nrog phenylethanoid glycosides thiab lignans, uas ntseeg tau tias muaj cov khoom tiv thaiv kab mob. Los ntawm kev txo cov kab mob hauv cov hnyuv, nws tuaj yeem pab txhim kho kev zom zaub mov tsis tu ncua thiab txo qhov cem quav.
