In IBS, a smartphone application for self-managing a FODMAP-lowering diet vs. otilonium bromide reduced symptoms at 8 wk

The DOMINO trial randomized 459 primary care patients with irritable bowel syndrome (IBS) to receive eight weeks of otilonium bromide (40 mg three times per day) or a fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP)-lowering smartphone application. Researchers compared IBS Symptom Severity Score and the proportion of responders (improvement ≥50 points) in all patients and the subgroup fulfilling Rome IV criteria (Rome+). The responder rate after eight weeks of treatment was significantly higher with diet compared with the antispasmodic (71% vs. 61%; P=0.03) and was more pronounced in Rome-positive patients (77% vs. 62%; P=0.004). Patients allocated to the diet group were 94% adherent, compared with 73% of the medication group.

The study was published online on April 28 by Gut. The following commentary by John F. Cox III, MD, FACP, was published in the ACP Journal Club section of the August Annals of Internal Medicine.

IBS is a disorder of “gut–brain interaction.” Many patients' symptoms seem to be triggered by certain foods, and visceral hypersensitivity and psychosocial factors also play roles. The British Society of Gastroenterology recommends increasing soluble fiber intake and regular physical activity. If this does not lead to substantial improvement, second-line dietary therapy with a low-FODMAP diet is recommended. Because this diet may alter the microbiome, subsequent reintroduction of FODMAP foods, as tolerated, is recommended. Ideally this would be done under supervision of a trained dietitian, but this can be difficult to implement in primary care due in part to the cost of dietetic services. Pharmacotherapy guided by type of IBS is used when needed and can include antispasmodics. Comprehensive patient education, including dietary advice and monitoring, can be challenging in primary care practice because of time pressure.

Enter the DOMINO trial, studying a primary care population with <10% loss to follow-up over 24 weeks. It found that a smartphone FODMAP-lowering diet application, designed using [self-determination theory] SDT, reduced IBS symptom severity more than the antispasmodic otilonium bromide. Neither patients nor investigators were blind to the interventions.

Delivery of the dietary intervention via an application seems a helpful way to educate patients about diet and augment the provider–patient relationship outside of the primary care visit. Indeed, some of the intervention effect is probably from the additional support to patients' autonomy, independent of change in diet.

DOMINO supports further development and use of technology, such as the FODMAP-lowering diet application, to enhance dietary counseling for, and improve care of, patients with IBS.