Letter to the Editor: Survey-Based Analysis of Clinical Treatment Status of Irritable Bowel Syndrome in Korea: Suggestions for Future Research

Abstract

To the Editor: A recent article analyzing the clinical treatment patterns of irritable bowel syndrome (IBS) in Korea1 was very impressive and noteworthy. According to this study, doctors diagnose and treat IBS based on the Rome IV criteria, which are more stringent than the Rome III criteria.2 However, rates of colonoscopy; need for random biopsy; perception of ineffectiveness of low fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) diet treatment; and treatment choice for constipation- or diarrhea-predominant subtypes varied significantly between physicians in primary/secondary and tertiary institutions. This study is significant in that it presents the current clinical status of diagnosis and treatment of IBS, which could be the cornerstone for national specific treatment guidelines,3 and I would like to discuss several issues for further research in this regard. The first is multidisciplinary management. IBS is a well-known disorder of brain–gut interaction. People with IBS have a threefold higher risk of anxiety and depression than healthy individuals.4 The prevalence rates of anxiety and depressive symptoms in patients with IBS are 39% and 29%, respectively.4 A bidirectional association between gastrointestinal symptoms and psychological comorbidities has been suggested, and the latter is considered to have a decisive impact on the reduced quality of life.5 While the prevalence of anxiety and depression has increased globally, the COVID-19 pandemic has accelerated this, and IBS is a component of post-COVID-19 syndrome.6 7 Therefore, physicians need to take a more in-depth approach to psychological factors and gastrointestinal symptoms.7 In this regard, the authors analyzed the timing and duration of tricyclic antidepressant treatment.3 Seventy-two percent of the physicians responded positively to the effectiveness of antidepressants in managing IBS-related pain. The most frequent timing of prescription was 4 and 8 weeks after initial pharmacological therapy. The administration periods were usually within 4 weeks, and physicians at primary and secondary healthcare institutions tended to prescribe for longer periods. However, as the authors mentioned, tricyclic antidepressants have generally been used for a short period of time because of their adverse effects, and selective serotonin reuptake inhibitors, an alternative to tricyclic antidepressants, have limitations in prescription because of insurance regulations in Korea. Therefore, physicians inevitably face difficulties in properly evaluating a patient’ psychological factors or confirming drug response, and their treatment requires integrated care including psychological therapy, primary medical treatment, and dietary modification. Thus, psychiatric referral analyses according to the type of practice would be helpful in determining the perception of psychological factors and improving multidisciplinary management. The second issue concerns diet and traditional medicine. The prevalence and treatment patterns of IBS vary according to geographical and demographic differences. Traditional Korean food includes white rice and several side dishes containing kimchi. It is difficult to accurately calculate the FODMAP content because of complex recipes that contain more than 25 ingredients per meal.2 Kimchi also contains FODMAP-rich ingredients; however, interestingly, it has a low correlation with food-related IBS symptoms.8 The food that was most associated with IBS symptoms was whole milk (34.7%), followed by instant ramen (28.7%), black bean sauce noodles (24.8%), and pizza/hamburger (23.8%).9 Therefore, direct application of the low FODMAP diet protocol developed in western studies is not appropriate for Asians including Koreans,8 10 who have different dietary cultures, and these factors should be considered as one of the causes of the ineffectiveness of low FODMAP diet treatment. Thus, knowledge regarding food composition and individualized dietary guidance are required instead of low FODMAP diet recommendations. In addition, herbal medicines and treatments are readily available in Asian countries. In Korea, traditional medicine is currently used under the National Health Insurance system to manage IBS.2 Therefore, a significant number of patients visiting hospitals may be simultaneously taking herbal or traditional medicine at the same time. Thus, physicians should be aware of this in clinical practice. We hope that these issues will be considered in future studies.