Irritable Bowel Syndrome -- Avoid Drugs
Abnormalities in colonic fermentation may be a cause of irritable bowel syndrome. According to the researchers, measurements of participant colonic gas production taken during trial diets suggested that irritable bowel syndrome may be caused by abnormal fermentation. Baseline rates of gas excretion were much higher among IBS patients than controls. In four of the six IBS patients, symptoms occurred when gas excretion was rapid. In addition, the researchers observed that on an exclusion diet, which significantly improved symptoms, gas excretion (hydrogen and methane) fell dramatically, but no such change occurred in controls. The researchers point out that fecal analysis revealed no evidence of malabsorption of substrate, suggesting that reductions in gas excretion were due to fermentation changes, not reductions in the amount of substrate entering the cecum.
Lancet October 10, 1998;352:1187-1189.
COMMENT: There are about 60 trillion bacteria in the intestinal tract and there are about 6 trillion cells in our body, so the bacteria outnumber us ten to one. Keeping the gut healthy is the key to good health. This study highlights an important concept in health. The food one eats will influence the type of bacteria that is growing in the colon. If one consumes large amounts of grain carbohydrates and sugar, this will encourage growth of bacteria whose digestion end products will not promote good health in our systems. Good bacteria concentrates, like Flora Source, will facilitate the production of healthier bacteria, but limiting the grains and sugars seems to be the foundational key to good colon health for most of us.
Several months ago we reported about the petition to the FDA by the consumer advocacy group Public Citizen that the Irritable Bowel Syndrome (IBS) drug Lotronex be pulled from the market. Well, now comes word that the drug's manufacturer has decided to volunarily pull the drug, after sending dozens of people to the hospital and possibly causing the deaths of at least three and possibly more users.
Glaxo Wellcome Inc. announced it was withdrawing its drug Lotronex under pressure from the Food and Drug Administration despite the fact that the company maintains the medication is safe.
Lotronex was approved less than 10 months ago as a highly effective alternative for the disabling condition and quickly became a popular drug, with 450,000 prescriptions being written for it since March.
Yesterday's withdrawal again raised questions about whether the FDA is approving too many drugs too quickly. Lotronex is the third prescription drug to be withdrawn from the market this year because of safety concerns, and the seventh to be withdrawn in the last three years.
"The red flag was up very high and early on this one, and unfortunately the FDA and the company did not pay attention," said Sidney Wolfe of the consumer group Public Citizen, which had petitioned recently for the removal of Lotronex. "The FDA was bending over backwards to keep it available, when they should have been pushing hard to get it removed."
The drug's primary complications have been severe constipation and ischemic colitis. Ischemic colitis is a reduction of blood flow to the gut that can cause severe pain and bloody stools that can lead to potentially fatal bleeding and infections.
Colitis was first identified as a side effect in early trials of the drug, but that problem appeared at the time to go away as soon as users stop taking the medication.
As additional cases of complications appeared after the drug reached the market in March, the FDA in August issued a warning to patients and doctors about the possible side effect.
After even more cases arose, the agency asked Glaxo to significantly restrict distribution of the drug, but the company decided to withdraw it instead.
"We have become increasingly concerned of the risk-benefit profile of the drug, especially with serious complications from ischemic colitis and serious constipation, and some death," Victor Raczkowski, of the FDA's office of drug evaluation said. He said there had been 70 cases of ischemic colitis or severe constipation strongly associated with Lotronex use reported as of Nov. 10, as well as the three deaths, although the Associated Press has said that FDA documents had linked eight deaths to the drug.
Washington Post, November 29, 2000; Page A01
DR. MERCOLA'S COMMENT: This is a good example of how you can learn about dangers such as this drug months before it is pulled off the market, as we reported about Public Citizen's petition a while ago. Hats off to Public Citizen for another successful campaign.
By Denise Grady
For the first time, the Food and Drug Administration is allowing a drug to go back on the market after it was removed for safety reasons.
The drug, Lotronex, a prescription treatment for irritable bowel syndrome, will be available again in several months.
Lotronex was taken off the market in November 2000, less than 10 months after it was approved, because it was linked to severe intestinal problems and several deaths. GlaxoSmithKline, based in Britain, withdrew the drug voluntarily at the F.D.A.'s request when the two could not reach an agreement on marketing restrictions intended to reduce adverse reactions.
But thousands of patients protested the withdrawal, saying Lotronex was the only treatment to have aided them. Their pleas helped to persuade the agency and manufacturer to find a way to reinstate it.
Lotronex will return, the agency said - with restrictions. The new rules leave considerable responsibility with doctors, pharmacists and patients to use it correctly and to watch for early signs of intestinal problems, which can be fatal.
Dr. Victor Raczkowski, deputy director of the F.D.A. office that evaluates gastrointestinal drugs, said that the return of Lotronex was "not part of any overall F.D.A. strategy to bring back withdrawn drugs." Rather, he said, it was a unique case in which the agency took an unusual action to help desperate patients who had no other effective treatment.
Before Lotronex was pulled from the market, a month's supply cost $175. A GlaxoSmithKline spokeswoman said the price would rise because of the costs attached to the new marketing plan.
GlaxoSmithKline's shares rose 2.8 percent in London trading yesterday.
Lotronex was the first drug shown to be effective specifically for irritable bowel syndrome. When it was first marketed, some financial analysts predicted Lotronex would become a blockbuster treatment for GlaxoSmithKline. But it did not get the chance to become one and is unlikely to do so now, some analysts say, because of the restrictions.
At its sales peak, about 275,000 people used Lotronex. But it was withdrawn after 70 patients developed severe constipation or ischemic colitis, a lack of blood flow to the bowel. Some needed surgery. Three deaths were linked to Lotronex use.
More reports came in later. The F.D.A. said yesterday that as of March 8, it had been notified of 84 cases of ischemic colitis and 113 cases of serious complications from constipation. Of those with ischemic colitis, 54 were hospitalized, 11 needed surgery and 2 died. Of the constipation cases, 83 were hospitalized, 34 had surgery and 2 died.
Even so, many other Lotronex users said that they had essentially been homebound by pain and severe diarrhea, and that Lotronex had enabled them to live normal lives for the first time in years.
Doctors who studied the drug said it greatly helped some patients, did little or nothing for many, and greatly harmed others. But it was impossible to predict into which group a patient would fall.
Under the new rules set by the F.D.A., doctors who want to prescribe Lotronex will have to enroll in a program run by GlaxoSmithKline that requires them to "self attest" that they know how to diagnose and treat irritable bowel syndrome, how to prescribe Lotronex and how to recognize and treat complications.
The doctors must also agree to explain the drug's risks and benefits to patients, give them the company's informational pamphlet and report serious adverse effects to GlaxoSmithKline or the F.D.A.
Any doctor can get into the program by self attesting. Those who do not feel qualified to prescribe the drug can take an as yet undeveloped course from GlaxoSmithKline.
Patients who want Lotronex must sign an agreement acknowledging its risks, which include a 1-in-1,000 chance of serious constipation problems and a 1-in-350 chance of ischemic colitis. Patients must also pledge to call their doctors immediately if they develop any symptoms considered to be dangerous, including constipation, new or worse bowel pain or blood in their stools.
Doctors in the program will be given special stickers to apply to prescriptions for Lotronex, and the drug's labeling will alert pharmacists not to fill prescriptions that lack stickers. Pharmacists will also be instructed not to allow refills or prescriptions that are telephoned or faxed in, to insure that patients keep in contact with their doctors.
The new plan also cuts the dose in half, to one milligram a day.
Lotronex was first approved for women with chronic diarrhea from irritable bowel syndrome, but it is now recommended only for a narrower group: women with very severe cases that have not responded to other drugs. The group amounts to less than 5 percent of all people with irritable bowel syndrome, and is estimated to be about 185,000 women.
New York Times June 6, 2002
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