William Chey, MD, Explores Integrated Care for IBS Treatment at ACG 2021

William D. Chey, MD, FACG

William D Chey, MD, FACG professor of gastroenterology and nutrition sciences at Michigan Medicine at the University of Michigan, gave The J Edward Berk Distinguished Lecture at the American College of Gastroenterology 2021 conference. Chey’s lecture was titled “The End of the Beginning: Megatrends in Gastroenterology”.

“I think we're in an incredibly exciting time in gastroenterology,” Chey said. “And I don't say that lightly because I understand, as a clinician, all the challenges that we face in the clinic every day.”

Chey described the treatment of irritable bowel syndrome (IBS) as a team sport. It’s no longer only about gastroenterologist care but an integrated team involving dietitians, behavioral therapists and possibly even complementary alternative medicine providers.

Diet therapies are a cornerstone of treatment. When talking to patients with IBS, they almost invariably say that the 2 biggest triggers for their symptoms are when they eat and when they’re stressed or anxious.

“Trying to create solutions to address those realities are critically important,” Chey said. “And in fact, they’re evidence based now.”

The low FODMAP diet, the Mediterranean diet, increased fiber, are a few examples of potential dietary solutions that Chey mentioned. Currently, the low FODMAP diet is the most evidence-based diet strategy for patients with IBS.

“When comparing to a habitual diet, the low FODMAP diet is the most effective diet intervention that’s been evaluated in randomized controlled trials,” Chey explained.

While the dataset surrounding the low FODMAP diet is imperfect, in general the data are trending in a positive direction. In addition to improving overall symptoms, the FODMAP diet has been shown to be effective for abdominal pain and bloating.

When treating patients with IBS, diet behavior and medication are equally important. Psychological treatments should be considered with any level of gastrointestinal (GI) symptoms.

Compared to 7 or 8 years ago when it was common practice to only consider psychological treatment in cases with severe GI symptoms, it’s a paradigm shift. The patient’s insight into the relationship between anxiety and their GI symptoms is really the key, Chey said.

A patient who has the insight and is willing to engage and follow up with a therapist is an excellent candidate for behavioral therapy regardless of whether they have mild, moderate or severe symptoms.

“For patients with IBS, the most efficacious behavioral interventions were minimal contact cognitive behavioral therapy,” Chey explained.

Gut-directed hypnosis and cognitive behavioral therapy (CBT) were found to be more efficacious than education or routine care after being evaluated in randomized control trials. This shows that a multidisciplinary care model is an ideal treatment approach.

Moving away from treatment silos and into an integrated care model is where we want to go, Chey said. Collaborative, multi-specialty care that’s team-based with the patient at the center.

Chey shared the details of a randomized controlled trial conducted in Australia that focused on traditional care versus integrated care models. Until this point, there hasn’t been evidence-based support showing that integrated care is a better method until this publication.

The study showed a group of individuals with a diverse set of functional GI disorders (65% IBS) that 84% reported on verbal response of their symptoms with integrated care compared to 57% with the traditional care model. Even when looking at the cohort of individuals with IBS, the benefit offered by integrated care was statistically significant.

“So, multidisciplinary integrated care models improve clinical outcomes," Chey said. “I've shown you that they may reduce costs, there's some data to suggest that perhaps you could build an argument for that, and they redistribute responsibilities in ways that benefit patients and providers.”