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AGA Clinical Practice Update on Management of Chronic Gastrointestinal Pain in Disorders of Gut–Brain Interaction: Expert Review

  • Laurie Keefer
    Affiliations
    Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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  • Cynthia W. Ko
    Correspondence
    Reprint requests Address requests for reprints to: Cynthia W. Ko, MD, MS, Division of Gastroenterology, University of Washington, Box 356424, Seattle, Washington 98195. fax: (206) 685-8684.
    Affiliations
    Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
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  • Alexander C. Ford
    Affiliations
    Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, United Kingdom

    Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds, United Kingdom
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      Description

      This expert review summarizes approaches to management of pain in disorders of gut–brain interaction. This review focuses specifically on approaches to pain that persist if first-line therapies aimed at addressing visceral causes of pain are unsuccessful. The roles of a therapeutic patient–provider relationship, nonpharmacologic and pharmacologic therapies, and avoidance of opioids are discussed.

      Methods

      This was not a formal systematic review but was based on a review of the literature to provide best practice advice statements. No formal rating of the quality of evidence or strength of recommendation was performed. BEST PRACTICE ADVICE 1: Effective management of persistent pain in disorders of gut–brain interaction requires a collaborative, empathic, culturally sensitive, patient–provider relationship. BEST PRACTICE ADVICE 2: Providers should master patient-friendly language about the pathogenesis of pain, leveraging advances in neuroscience and behavioral science. Providers also must understand the psychological contexts in which pain is perpetuated. BEST PRACTICE ADVICE 3: Opioids should not be prescribed for chronic gastrointestinal pain because of a disorder of gut–brain interaction. If patients are referred on opioids, these medications should be prescribed responsibly, via multidisciplinary collaboration, until they can be discontinued. BEST PRACTICE ADVICE 4: Nonpharmacologic therapies should be considered routinely as part of comprehensive pain management, and ideally brought up early on in care. BEST PRACTICE ADVICE 5: Providers should optimize medical therapies that are known to modulate pain and be able to differentiate when gastrointestinal pain is triggered by visceral factors vs centrally mediated factors. BEST PRACTICE ADVICE 6: Providers 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.

      Keywords

      Abbreviations used in this paper:

      5-HT (5-hydroxytryptamine), CAPS (centrally mediated abdominal pain syndrome), DGBI (disorders of gut–brain interaction), FD (functional dyspepsia), IBS (irritable bowel syndrome), PPI (proton pump inhibitor), RCT (randomized controlled trial), SNRI (serotonin-norepinephrine reuptake inhibitor), SSRI (selective serotonin reuptake inhibitor), TCA (tricyclic antidepressant)
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