치료원칙
- 치료 목표: 다양한 병태생리를 고려하면서 가장 불편한 증상을 완화하여 삶의 질 제고
- 치료전략
- 우선 환자를 정신적으로 안심시켜 줄 것
- 장관의 운동과 감각을 자극하는 국소인자가 있는지를 조사하여 교정할 것
- 우세한 증상을 파악하고, 해당 증상으로 분류한 아형군에 따른 치료시행
식이: 저 FODMAP 식이
- 증상을 악화시키는 음식의 제한은 과민대장증후군의 치료에 도움을 줄 수 있다.
FODMAPs이란?
- fermentable, oligo-, di-, mono-saccharides, and polyols의 첫 글자의 약자
- 장내에서 발효되기 쉬운 올리고당, 이당류, 단당류 그리고 폴리올을 뜻하는 약자
| 특징 | 주요 함유 음식 |
단당류 |
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이당류 |
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올리고당류 |
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폴리올 |
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FODMAP의 병태생리
올리고당은 소화되어 흡수되지는 않지만 장내 세균이 충분히 이용 가능한 에너지원으로 작용할 수 있습니다. 정상인의 경우, FODMAPs에 의해서 발생한 장내 수분 증가와 가스 발생으로 인한 증상은 거의 나타나지 않는 반면, 기능성 위장관질환 특히 과민대장증후군의 경우는 내장과민성이나 뇌-장축에 문제가 있는 경우가 흔하므로, 이렇게 발생한 가스와 수분에 의해 충분히 증상이 유발될 수 있습니다. |
저 FODMAP 식이의 실제
약물요법
약물 치료의 변화
전통적인 약물 치료 | ▶ | 최근의 약물치료 트렌드 |
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국내외 권고안: ACG(American College of Gastroenterology) 권고안(2014), 국내 가이드라인(2011)
치료방법 | ACG 권고안 | 국내권고안 | ||
권고안 | 권고강도 | 증거수 |
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변비완하제: Psyllium | Psyllium, but not bran, provides overall symptom relief in IBS (data presented for psyllium). | Weak | Moderate |
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변비완하제: polyethylene glycol | There is no evidence that polyethylene glycol improves overall symptoms and pain in patients with IBS. | Weak | Very low |
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Prebiotics/synbiotics | There is insuffi cient evidence to recommend prebiotics or synbiotics in IBS. | Weak | Very low |
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probiotics | Taken as a whole, probiotics improve global symptoms, bloating, and fl atulence in IBS. | Weak | Low |
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Rifaximin | Rifaximin is effective in reducing total IBS symptoms and bloating in IBS-D. | Weak | Moderate |
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antispasmodics | Certain antispasmodics provide symptomatic short-term relief in IBS. | Weak | Low |
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Peppermint oil | Peppermint oil is superior to placebo in improving IBS symptoms. | Weak | Moderate |
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지사제: loperamide | There is insuffi cient evidence to recommend loperamide for use in IBS. | strong | Very low |
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antidepressants | As a class, antidepressants are effective in symptom relief in IBS. | Weak | High |
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세로토닌 수용체에 작용하는 약물(Serotonergic agents) | Alosteron is effective in females with IBS-D. | weak | Moderate |
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Mixed 5-HT 4 agonists / 5-HT 3 antagonists are not more effective than placebo at improving symptoms of IBS-C. | strong | Low | ||
선택적 염소통로활성제 | Linaclotide is superior to placebo for the treatment of IBS-C. | strong | High |
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Lubiprostone is superior to placebo for the treatment of IBS-C. | strong | Moderate |
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약물병용요법 |
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과민대장증후군의 약물치료
Predominant symptoms | First line | Second line |
Pain |
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Diarrhea |
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Constipation |
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Bloating with distension |
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Bloating without distension |
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증상별 약물치료
- 변비를 호소하는 경우: 섬유질 섭취, osmotic laxatives(magnesium hydroxide), stool softner, stimulant laxatives, 5-HT4 agonists, Chloride channel activator
- 설사를 호소하는 경우: loperamide, diphenoxylate, 5-HT3 antagonists
- 복통을 호소하는 경우: antispasmodics(smooth muscle relaxant), antidepressants(TCA, SSRI)
증상별 주로 사용되는 약물
증상 유형 | 약물종류 | regimen |
복통 | Smooth muscle antispasmodics | Dicycylomine (10-20 mg 1-4 times a day) Otilonium (40-80 mg 2-3 times a day) Mebeverine (135 mg 3 times a day) |
Peppermint oil | Enteric-coated capsules (250-750 mg, 2-3 times a day) | |
Tricyclic antidepressants | Desipramine (25-100 mg every bedtime) Amitriptyline (10-50 mg every bedtime | |
Selective serotonin reuptake inhibitor | Paroxetine (10-40 mg once a day) Sertraline (25-100 mg once a day) Citalopram (10-40 mg once a day | |
5-HT3 antagonists | Alosetron (0.5-1.0 mg twice a day) | |
Constipation | Psyllium | Up to 30 g/day in divded doses |
Polyethylene glycol | 17-34 g/day | |
Chloride channel activators | Lubiprostone (8 μg twice a day) | |
Guanylate cyclase C agnosits | Linaclotide (290 μg once a day) | |
Diarrhea | Opioid agonists | Loperamide; 2-4 mg; when necessary, titrate up to 16 mg/day |
Bile salt sequestrants | Cholestyramine (9 g 2-3 times a day) Colestipol (2g 1-2 times a day) Cholesevelam (625 mg 1-2 times a day) | |
Probiotics | Multiple products available | |
Antibiotics | Rifaximin (550 mg po 3 times a day × 14 days) | |
5-HT3 antagonists | Alosetron (0.5-1.0 mg twice a day) Ondansetron (4-8 mg 3 times a day) Ramosetron (5 μg once a day) | |
Mixed opioid agonists/antagonists | Eluxadoline (100 mg twice a day) |
참고자료
- Kim JH, Sung IK. Strategy to Manage Irritable Bowel Syndrome in Korea. Korean J Med 2014;86:695-697
- Kim JH. Diet and Nutritional Management in Functional Gastrointestinal Disorder: Irritable Bowel Syndrome. Korean J Med 2016;90:105-110
- Kwon JG, Park KS, Park JH, et al. Guidelines for the Treatment of Irritable Bowel Syndrome. The Korean Journal of Gastroenterology 2011;57(2):82.
- Kim HJ. What is the FODMAP? Korean J Med 2015;89:179-185.
- Simrén M. Diet as a therapy for irritable bowel syndrome: progress at last. Gastroenterology 2014;146:10-12.
- Lee KJ. Treatment of Irritable Bowel Syndrome. Korean J Med 2011;80:499-504
- Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014;109 Suppl 1:S2–26; quiz S27.
- Park CH, Han DS. Pharmacotherapy of irritable bowel syndrome. J Korean Med Assoc 2017; 60(1):57-62
- Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56(12):1770–98.
- Mearin F, Lacy BE, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R. Bowel disorders. Gastroenterology 2016;150:1393-1407.e5.