Rome Foundation Review Provides Guidance for Use of Gut-Brain Modulators for Functional GI Disorders

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Douglas A. Drossman, MD, MACG, President of the Rome Foundation and Drossman Gastroenterology offers insight on new research published online in Gastroenterology, Neuromodulators for Functional GI Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report.  Central neuromodulators (antidepressants, antipsychotics and other CNS targeted medications) are increasingly used for treatment of functional GI disorders (FGIDs), now recognized as Disorders of Gut-Brain Interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations

  1. What’s new and/or what are the research highlights?

Drossman: This is the first and most comprehensive review of the use of central neuromodulators for painful functional gastrointestinal disorders (FGIDs) like irritable bowel syndrome (IBS), centrally mediated abdominal pain and other painful symptoms.  It is the culmination of an 18-month project (a Rome Working Team) where we did an evidenced-based review of the literature and consensus of experts to come up with recommendations.  One key point is that we are changing the use of antiquated terminology of “antidepressants” and “antipsychotics” which were developed originally to treat psychiatric disorders, and replacing with the term neuromodulators.  The new term reflects better our understanding that these are disorders of gut-brain interaction (Rome IV).

In that context, we are treating a dysfunctional brain-gut axis with these medications, often in doses lower than for treating major psychiatric disorders.  Some of the major findings are that tricyclic antidepressants (TCAs) and SNRIs do work for pain.  However, if a single medication does not work or has side effects, we employ the concept of augmentation (combining two or more treatments) to help those that don’t initially respond.  Also, patients are kept on them for a year or more for relapse prevention.  It is a way to provide ample time to reverse the dysfunctional circuitry causing the FGID problem in the first place, and it may reverse the neurodegeneration that occurs over time. Finally, if there are frequent side effects or a failure to respond we recommend doing pharmacogenomic testing, a new method to evaluate how patients genetically metabolize these medications.  Also, it’s important to realize that the ways in which we employ these treatments for FGIDs is different from how psychiatrists treat psychiatric disorders.  In fact, psychiatrists are not well versed in these methods.

  1. What do physicians need to know?

Drossman: This is a paradigm shift.  We are looking to re-educate clinicians to understand the value of these medications for GI pain, nausea, and bowel dysfunction in cases, particularly where traditional GI drugs don’t work.  Physicians are not aware of many of the newer methods for managing the FGIDs and feel poorly trained in the use of these medications.  The Rome Foundation is looking to increase this understanding.  This Rome Working Team report will be out in March in Gastroenterology currently online for access to those who have a journal subscription.

In addition, we will be holding a major symposium at DDW on Saturday June 2nd at the Washington convention center from 2-3:30 “Central Neuromodulators for Chronic GI Pain and FGIDs (DGBI) – A Rome Foundation Working Team Report”.  The speakers will be me, Alex Ford and Jan Tack.  In addition, on Sunday at DDW (June 3) there will be a breakfast session “Using Neuromodulators for Disorders of Brain Gut Interactions: A Primer for Clinicians” with myself and Harley Sobin, MD.  For this session, we will do some practical case based guidelines. Thus, we are beginning to see a major change in the acceptance and value of these treatments.

  1. What’s important for patients to know?

Drossman: They can be helped!  Additionally, patients should know that the Rome Foundation is reducing the sense of stigma by avoiding unnecessary attributions relating these treatments to psychiatric disorders.  We believe there will be a big difference in acceptance and benefit to patients over the next few years as more and more physicians use them with a proper understanding of how they can benefit these chronic gastrointestinal symptoms.  With regard to DrossmanCare – we have been taking care of hundreds of patients over the years in this manner and helping patients with the most refractory symptoms who have been to other medical centers without benefit.  In our practice [see below citation], the combination of good communication skills to help patients understand the physiological value of these medications coupled with our knowledge of selecting the best medications or combinations of medications to treat these FGIDs make a difference to help those that have previously failed treatment.  I left UNC in part out of a commitment to improve patients suffering from these disorders using these methods and now we see it happen.

Related Resources

“Central Neuromodulators for Chronic GI Pain and FGIDs (DGBI) – A Rome Foundation Working Team Report”, Gastroenterology. 2017 Dec 21. pii: S0016-5085(17)36718-5. doi: 10.1053/j.gastro.2017.11.279

Beyond Tricyclics: New Ideas for Treating Patients With Painful and Refractory Functional Gastrointestinal Symptoms, The American Journal of Gastroenterology(2009) 104, 2897–2902 (2009) doi:10.1038/ajg.2009.341


Rome Foundation’s Dr. Laurie Keefer, Featured in NBC News on Efficacy of Hypnosis for GI Disorders

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Dr. Laurie Keefer

Hypnosis is a well-recognized treatment for functional gastrointestinal disorders (FGIDs) including IBS with proven scientific benefit. Recently the news media has taken great interest in this treatment as shown in this NBC News feature that highlights Laurie Keefer, PhD from Mount Sinai Medical Center in New York. Dr. Keefer is a nationally recognized clinical psychologist who treats GI disorders including FGIDs with hypnosis. She is also a leading member of the Rome Foundation

In this video, Dr. Keefer explains why gastroenterologists are turning to psychologists for help with their patients who don’t get relief from medication. Hypnotherapy can be an effective treatment for heartburn and other stomach conditions. It’s a powerful alternative treatment, backed with scientific evidence, that is increasingly being offered at the nation’s leading medical centers.

Read the full NBC News article and watch the video

As a key member of the Rome Foundation, Dr. Keefer serves as a member of two Rome IV committees of the Rome IV book :  “Central Disorders of Gastrointestinal Pain” [Co-Chair] and “Biopsychosocial Aspects of Functional GI Disorders.  She also leads the Rome Foundation’s Psychogastroenterology Standing Committee which focuses on increasing the availability of GI-trained mental health professionals around the world.

Dr. Keefer is well known for her training of therapists in the implementation of evidence-based behavior therapies for GI diseases with an emphasis on gut-directed hypnotherapy and cognitive behavior therapy and is a sought-after lecturer on these topics.  She is also a member of Council for the American Neurogastroenterology and Motility Society.

In her current role at Icahn School of Medicine at Mount Sinai in New York City, Dr. Keefer oversees Psychobehavioral Research for the Division of Gastroenterology and also Co-Directs a patient-centered subspecialty medical home within the Susan and Leonard Feinstein IBD Clinical Center called GRITT-IBDTM [Gaining Resilience Through Transitions] which focuses on reducing negative outcomes for patients with inflammatory bowel disease by enhancing resilience with behavioral tools.  She remains committed to the development of self-management tools that leverage the strong brain-gut connection in order to improve outcomes for patients with chronic digestive diseases.

Rome Foundation Links Mind-Gut in Treating Chronic Digestive Disorders

The Rome Foundation has recognized the value of linking mind and gut in treatment of chronic digestive disorders and is now supporting the development of a Rome Psychogastroenterology Group (see information I’ve attached that you can expand upon about the group here).

The goal of this group is to connect mental health providers interested in treating patients with GI disorders, including FGIDs with the Rome Foundation and treating gastroenterologists.

This program will have dual benefits:

  1. To encourage mental health providers to go into this GI subspecialty and to gain knowledge from training programs provided by this group
  2. To become a resource for patients with FGIDS being treated by gastroenterologists as part of Rome Foundation’s educational initiative.

Mental Health Providers interested in Treating Patients with GI Disorders, please contact Dr. Laurie Keefer

Related Resources

Efficacy, Tolerability, and Safety of Hypnosis in Adult Irritable Bowel Syndrome: Systematic Review and Meta-Analysis, Psychosomatic Medicine 76:389Y398 (2014)

Long-Term Success of GUT-Directed Group Hypnosis for Patients With Refractory Irritable Bowel Syndrome: A Randomized Controlled Trial, The American Journal of Gastroenterology, Am J Gastroenterol  advance online publication, 19 February 2013;  doi: 10.1038/ajg.2013.19

GI Fellow Emily Rolfsmeyer, MD, Gains New Perspective on Treating Patients with FGIDs February 2015

Drossman Care News Blog Comments Off on GI Fellow Emily Rolfsmeyer, MD, Gains New Perspective on Treating Patients with FGIDs February 2015 , , ,

image2I am currently a GI fellow at OHSU in Portland, OR, and as a part of the American Neurogastroenterology and Motility Society’s clinical training program at UNC, I was scheduled to spend several days in Dr. Drossman’s functional GI clinic.  Given the significant overlap between gastrointestinal motility and functional disorders, this was quite an important component of my month-long motility training, but prior to my first encounter with Dr. Drossman, it simply felt like a box that needed to be checked, a rite of passage per se.  Little did I know, I was grossly underestimating the impact of this incredible experience.

Prior to my first encounter with Dr. Drossman, I had found these types of patients in my own fellows clinic to be incredibly difficult.  They had problems to which I couldn’t give an organic diagnosis – such as with labs, imaging, or endoscopic evaluation – and the treatments I was using were either poorly tolerated or just plain ineffective.  So seeing a simple chief complaint of bloating would incite feelings of insecurity, and the patient encounter would leave me feeling somewhat worthless and unfulfilled as a physician.  It was clearly frustrating for me, but I can only imagine how my patients felt.

It only took moments in Dr. Drossman’s office for me to realize that he is going where no other physician has gone.  He actively listens to his patients, not only hearing their GI concerns, but also taking into account the global aspects of their lives – both past and present – just listening, without a single interruption. Centuries after our forefathers in medicine sought to disconnect the mind and body, Dr. Drossman is finally bringing them back together and treating patients as a whole. He also surrenders the patriarchal physician-patient model and engages each patient in his or her care, allowing the patients to drive their own bus toward their well being, while providing them with the means and support to get there.

image1His knowledge of the pathophysiology of these functional GI disorders is insurmountable and he is able to communicate it in a language that is understood by all, so that after seeing dozens of doctors and undergoing testing ad nauseam, his patients finally have answers to why they feel the way they do.  This understanding is just the beginning of their journey to wellness.  He also provides options for novel therapies targeting the pathophysiologic pathway – fully understanding and explaining the mechanisms involved.  And they work.  Patients return having received great mental and physical benefit from this holistic approach.  And many of them have a new-found quality of life that they never imagined was possible.

Thanks to Dr. Drossman, I have returned home with a new perspective and a much more fulfilling approach.  I now see the bloating, the abdominal pain, the nausea, and other functional complaints with a sense of optimism.  By using the skills that I have learned from Dr. Drossman (and perhaps an occasional ‘phone a friend’ call for advice), I truly believe I can help make them well.  It was an opportunity that has shaped my career and for which I will forever be thankful.

And finally, a special thank you to Dr. Drossman’s excellent PA, Kellie Bunn, as well, who knows more about treating functional GI disorders than I probably ever will!

Emily Rolfsmeyer, MD
Currently a GI fellow at OHSU in Portland, OR


Don’t Miss Free Webinar: “A Multi-Dimensional Approach to Treating Functional Gastrointestinal Disorders” November 2014

Dr. Douglas Drossman Blog Comments Off on Don’t Miss Free Webinar: “A Multi-Dimensional Approach to Treating Functional Gastrointestinal Disorders” November 2014 , , ,

11-19-2014 11-43-25 AM GI Circle Logo1Managing patients with functional gastrointestinal disorders is one of the most challenging areas of medicine. Although diagnosis is typically achieved using the Rome Criteria, treatment depend on the patient’s report of symptom response. But what is the most effective way to use this patient-reported information to determine the best treatment approach?

Join me and my colleagues, D.  Lin Chang and Dr. William Chey, as we  discuss why FGIDs are biopsychosocial disorders, present an overview of a more comprehensive approach to treating patients with functional gastrointestinal disorders, and explain how the Multi-Dimensional Clinical Profile (MDCP) can help you address the full spectrum of treatment options available to help your patients.

We will take your questions immediately following the presentation.

Join us on Wednesday, December 17, 2014 6:00 PM – 7:30 PM EDT

Register Now

Doug-Drossman1Douglas A. Drossman, MD, MACG

President, Rome Foundation
President, Drossman Center for the Education and Practice of Biopsychosocial Care LLC
Professor Emeritusof Medicine and Psychiatry,
University of North Carolina School of Medicine
Former Co-Director, UNC Center for Functional GI and Motility Disorders

lin changLin Chang, MD, FACG
Professor of Medicine
Co-Director, Center for Neurobiology of Stress
Division of Digestive Diseases
David Geffen School of Medicine at UCLA


CheyWilliam D. Chey. MD, FACG
Professor of Medicine
Director, GI Physiology Laboratory
Director, Michigan Bowel Control Program
Division of Gastroenterology
University of Michigan Health System
Ann Arbor, MI


Space is limited.  Reserve your webinar seat now!
Submit Your Questions in Advance to jgaulin@gi.org

After registering, you will receive a confirmation email containing information about joining the webinar.

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Douglas A. Drossman, MD