Clinical Question

Is using a smartphone application to increase adherence to a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet or an oral antispasmodic agent (otilonium bromide [not available in the United States]) more effective for the treatment of irritable bowel syndrome (IBS)?

Bottom Line

The pragmatic trial found a clinically meaningful benefit of a low FODMAP diet, implemented using a smartphone application, compared with an active medication. Because of its safety and low cost, the authors state that a low FODMAP diet should be first-line therapy for patients with IBS. The process includes eliminating FODMAP foods from the diet and reintroducing them one at a time until the offending food or foods are identified. The smartphone application used in the Belgian study was in French and Dutch, but there are many highly rated applications available. (Level of Evidence = 1b−)

Synopsis

Low FODMAP diets and otilonium bromide have been shown in randomized trials to be effective for the treatment of IBS. FODMAPs are short-chain carbohydrates that are poorly absorbed by some people. The trial enrolled primary care patients who were diagnosed with IBS by their physician. Patients with psychiatric comorbidity, who had used a FODMAP diet, or who had taken otilonium bromide were excluded. The dietary intervention consisted of a smartphone application that provided guidance for a low FODMAP diet and provided more than 100 recipes; the patients in the otilonium bromide intervention were given 40 mg three times daily. Groups were similar at baseline, with a mean age of 41 years, and 76% were female. Analysis was by intention to treat. The primary outcome was a clinically significant improvement of 50 points on the 500-point IBS-Symptom Severity Scale. A response was noted by more patients in the FODMAP group than in the otilonium bromide group at four weeks (62% vs. 51%; P = .02; number needed to treat [NNT] = 9) and eight weeks (71% vs. 61%; P = .03; NNT = 10). The average decline in the severity score was significantly higher in the FODMAP group (−97 vs. −77 points; P = .02). There were no differences between groups in overall quality-of-life scales. The authors prespecified a subgroup analysis of the 309 patients (70%) who met the Rome IV criteria for IBS. The benefit was greater in these patients in terms of the percentage of responders (77% vs. 62%; P = .004; NNT = 7). Adherence was higher for the diet than the medication (94% vs. 73%).