New best practice advice tackles pain in disorders of gut-brain interaction

An expert review from the American Gastroenterological Association cautioned against using opioids to treat pain from irritable bowel syndrome, functional dyspepsia, or centrally mediated abdominal pain syndrome, among other advice.

Experts from the American Gastroenterological Association (AGA) recently offered advice on managing chronic gastrointestinal pain in disorders of gut-brain interaction (DGBI), including irritable bowel syndrome, functional dyspepsia, and centrally mediated abdominal pain syndrome.

The AGA commissioned an expert review on DGBI, focused specifically on approaches to take when first-line therapies to address visceral causes of pain are unsuccessful. The experts informally reviewed the literature to provide a series of best practice advice statements, without formal ratings of the quality of evidence or strength of recommendation. The resulting six statements, listed below, were approved by the AGA and published by Clinical Gastroenterology and Hepatology on July 3.

  • Effective management of persistent pain in DGBI requires a collaborative, empathic, culturally sensitive patient-clinician relationship.
  • Clinicians should master patient-friendly language about the pathogenesis of pain, leveraging advances in neuroscience and behavioral science. Clinicians must also understand the psychological contexts in which pain is perpetuated.
  • Opioids should not be prescribed for chronic gastrointestinal pain due to a DGBI. If patients are referred on opioids, these medications should be prescribed responsibly, via multidisciplinary collaboration, until they can be discontinued.
  • Nonpharmacological therapies should be considered routinely as part of comprehensive pain management, and ideally brought up early on in care.
  • Clinicians should optimize medical therapies that are known to modulate pain and be able to differentiate when gastrointestinal pain is triggered by visceral factors versus centrally mediated factors.
  • Clinicians should familiarize themselves with a few effective neuromodulators, knowing the dosing, side effects, and targets of each, and be able to explain to the patient why these drugs are used for the management of persistent pain.

Management of persistent pain in DBGI is challenging and complex. Patients frequently present with co-existing psychiatric comorbidities and a limited range of coping skills, the experts noted. In patients who do not respond to the measures outlined here, involvement of a pain management specialist may be required. Overall, management of patients with DGBI with persistent pain requires a multi-pronged approach to optimize patient outcomes.